191500609-3-20-2023-28-AS-RORN-CVUSSD-20230920140746

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 03/10/2023
Date Signed: 03/20/2023 10:13:12 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/06/2023 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230306102542

FACILITY NAME:	SAN DIMAS RETIREMENT CENTER		FACILITY NUMBER:	191500609
ADMINISTRATOR:	PRISCILLA GAYTAN		FACILITY TYPE:	740
ADDRESS:	834 WEST ARROW HIGHWAY		TELEPHONE:	(909) 599-8441
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	343	CENSUS: 145	DATE:	03/10/2023
		UNANNOUNCED	TIME BEGAN:	09:49 AM
MET WITH:	Assistant Administrator Priscilla Gaytan		TIME COMPLETED:	03:39 PM

ALLEGATION(S):

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Staff are not preventing resident from verbally abusing another resident.
Staff did report incident(s) to appropriate agencies.

INVESTIGATION FINDINGS:

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**** This amended report supersedes report dated 03/10/2023. It was created to remove identifying information from original 9099 and 9099C. The additional revision did not change any other aspects of the report and all aspects including the findings remain the same. ***

Licensing Program Analyst (LPA) Alberto Lopez conducted a complaint investigation regarding the allegations listed above. LPA met with Assistant Administrator, Priscilla Gaytan, and explained the purpose of the visit.

LPA obtained copies of the Resident roster, Staff roster, SIR Dated 3/08/2023 Behavioral Contract for R12 dated 12/2/2021. R1 and R12 Physician’s report for Residential care facilities for the elderly. Interviews were held with the Administrator, Assistant Administrator, W1, 3 Staff, and 14 Residents today.

(CONTINUED ON 9009C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230306102542

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SAN DIMAS RETIREMENT CENTER	FACILITY NUMBER: 191500609
	VISIT DATE: 03/10/2023

NARRATIVE

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Allegation – Staff are not preventing resident from verbally abusing another resident. It is alleged that R12 is bullying and calling R1 vulgar words and impeding R1 movement in facility and that facility has not addressed the issue to make it stop.

The investigation revealed the following: Administrator stated that she had conversations with both residents and offered to mediate between them, but residents refused. Administrator stated that she offered to move R1 to another room and R1 refused the offer. Police investigated the incident and did not file report and asked R1 and R12 to just stay away from each other. R1 stated that since incident on 03/02/2023 and facility intervention, R12 has not been insulting R1 or others. R12 stated that R12 was nasty to some people because R12 stated that R1 blocks R12 passage with R1 wheelchair by traveling on wrong side of hallway and that triggers it. R12 stated that is a personality conflict and nothing more. R12 stated that R12 spoke with police and facility administrator about this incident. LPA interviewed 14 residents and 12 of 14 have never encounter any residents being rude or insulting to them or others. Facility did intervene on timely manner to prevent this from escalating and continuing according to statement from R1. R1 stated R1 is satisfied with what facility has done to address this situation.

Allegation: Staff did report incident(s) to appropriate agencies. It is alleged that facility staff failed to report the incident that occurred on 03/02/2023 to appropriate agencies and previous incidents.

The investigation revealed the following: Interview with Assistant Administrator reveled that the incident was reported to CCLD and ombudsman on 03/08/2023 which is within the required time frame that reports must be submitted. Assistant Administrator stated that no other reports had been made to facility previously regarding the 2 residents. R1 stated that this is the first time R1 reported this incident to facility and had not made any previous reports or complaints regarding R12. R12 stated R12 did not file any reports at all. W1 stated W1 assumed that previous incidents if any between the residents had been reported to facility and facility failed to report to appropriate agencies which is not the case as this was the first report made by R1.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

An exit interview was conducted with Assistant Administrator Priscilla Gaytan and copy of this report was provided..

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2023

LIC9099 (FAS) - (06/04)

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