191500609-11-28-2023-28-AS-LHIS-CY8KPX-20231205070526

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 11/28/2023
Date Signed: 11/28/2023 02:19:41 PM

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
08/15/2022 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220815140709

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: 133	DATE:	11/28/2023
		UNANNOUNCED	TIME BEGAN:	11:56 AM
MET WITH:	Pricilla Gaytan, Administrator.		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff behavior poses as a risk to a resident while in care.
Staff do not provide adequate food service to a resident.
Resident is not being treated fairly while in care.
Staff are retaliating against a resident.

INVESTIGATION FINDINGS:

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LPA Alberto Lopez made a subsequent unannounced complaint visit to deliver findings and met with Administrator Priscilla Gaytan and explained the purpose of the visit.

The investigation consisted of interviews with Administrator and 5 staff (S#1- S#6) (S1-S6) and 13 residents (R#1-R#13) R1-R13. LPA toured the kitchen and obtained resident and staff roster as well as menus for the 2 weeks and alternate menu for residents who would like to substitute any items for lunch and dinner. R1 Physicians report.

The investigation revealed:
Allegation: Staff behavior poses as a risk to a resident while in care. It is alleged that resident became distressed due to interaction with Administrator and Assistant Administrator. That Administrator does not treat resident with dignity and respect which has caused resident to suffer emotional distress. 4
(continued on 9909C)

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: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

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-20220815140709

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: 11/28/2023

NARRATIVE

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LPA interviewed thirteen residents and 13 of 14 residents could not collaborate the allegation, 6 of 6 staff denied the allegation. Some staff stated that they are trained to be of service to clients and de-escalate when appropriate. Both the Administrator S1, and Assistant Administrator S2 denied the allegation. S2 stated she never set up meeting with R1. S1 denied being rude to R1. Most residents stated that staff is very kind and respectful. There is insufficient evidence to support this allegation.

Allegation: Staff do not provide adequate food service to a resident. It is alleged that R1 cannot select 2 alternatives from food menu. That there is not enough food served to R1

LPA interviewed 13 residents and 12 of 13 could not collaborate the allegation. 12 of the 13 residents stated that they are only allowed 1 alternative and that it has been this way since they have been here. All Kitchen staff and Administrator stated that R1 gets double portions of everything. Staff stated they provide residents with everything he asks for. S1 stated they can increase the amount of fruit on the plate, but the fruit is seasonal and cannot be substituted always. 12 of 13 residents stated that they get enough food and can get more if they ask. Most residents stated that the food is plentiful. Some residents started the food is not very good in quality. There is insufficient evidence to support this allegation.

Allegation: Resident is not being treated fairly while in care. It is alleged that residents are not being treated fairly at the facility.

LPA interviewed six staff and 6 of 6 staff denied the allegations. LPA interviewed 13 residents and 12 of 13 residents stated they are treated fairly. LPA observed staff interactions during several visits and the staff treated all residents fairly and with respect and dignity. There is insufficient evidence to support this allegation.

Allegation: Staff are retaliating against a resident. It is alleged that staff is retaliating against resident for complaining.

LPA interviewed 6 staff and all 6 staff denied the allegations. 12 of 13 residents denied the allegation and some were surprised at the allegation. Most residents stated that they have never heard of staff retaliating against residents.

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.

Exit interview held. A copy of the 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: 11/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023

LIC9099 (FAS) - (06/04)

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