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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 12/12/2023
Date Signed: 12/12/2023 03:25:46 PM

Substantiated


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
03/14/2023 and conducted by Evaluator Alberto Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230314164113
FACILITY NAME:SAN DIMAS RETIREMENT CENTERFACILITY NUMBER:
191500609
ADMINISTRATOR:PRISCILLA GAYTANFACILITY TYPE:
740
ADDRESS:834 WEST ARROW HIGHWAYTELEPHONE:
(909) 599-8441
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:343CENSUS: 132DATE:
12/12/2023
UNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Anne GravesLVN TIME COMPLETED:
03:35 PM
ALLEGATION(S):
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Resident in care sustained unexplained injury.
Staff denied authorized representatives to access resident records.
Staff did not report incident to appropriate parties.
INVESTIGATION FINDINGS:
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LPA made subsequent visit to deliver findings on the above allegaions. LPA met with LVN Supervisor Anne Graves and discussed he purpose of the visit.

LPA reviewed and obtained R1 Physicians Report, other pertinant medcial infomation for R1, incident reports dated 09/25/2022 and 09/26/2022. Staff and residents rosters. LPA interviewed 7 staff, Staff #1-#7 (S1-S7) one (1) witness W#1 (family member), and 13 residents R#1-R#13 (R1-R13). LPA was unsuccessful in interviewing S8 after multiple attempts.

The investigation revealed:

Allegation: Resident in care sustained unexplained injury. It is alleged that resident in care had a fall on 09/25/2022 and facility could not provide explanation as to want transpired.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 28-AS-20230314164113
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: 12/12/2023
NARRATIVE
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LPA interviewed 7 staff S#1-S#7 including administrator. On 9/25/22 two staff S4 and S8 were attempting to change resident when resident fell to the ground and hit R14 face on R14 wheelchair footrest that were removed from R14 chair and were by the beside. Administrator stated she was not at facility when incident occurred and does not know how R14 got injured. S4 who was in the room when the incident happened stated she was helping S8 to get the R14 to bed and R14 was very agitated and didn’t want anyone to touch R14. S4 and S8 were able to get R14 in bed from wheelchair and R14 continues to fight with staff and yelling at them to not touch R14. S4 stated R14 struck S8 after we changed R14, and I went to get a dress from R14 closet and had my back turned and heard S8 yell and turned around to see R14 on the floor and R14 had thinks R14 struck R14 face on the wheelchair footrest. S4 stated she did her report and does not recall if R14 went to hospital that day. Supervisor S2 stated R14 was in chair and fighting the staff while they attempted to change R14. S2 stated R14 was in chair when R14 fell and that she may have hit the wheelchair footrest on the floor. Supervisor S3 did not remember what occurred. S5 (temporary Administrator) stated she didn’t know what happened. S5 stated that daughter was told about incident but not the extent of the injuries and did not recall the date. S6 stated she did not know anything about the incident. LPA attempted to contact S8 on more than 3 occasions and was unsuccessful. S8 is no longer employed at the facility. There were several differing explanations of how the bruises and injuries had occurred but none that fully explained what happened. Resident 14 was hurt, staff failed to properly assess R14 injuries, seek medical attention and did not send R14 to hospital until the next day. Therefore, based on the information gathered and the interviews conducted the allegation has been deemed Substantiated.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20230314164113
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: 12/12/2023
NARRATIVE
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Allegation: Staff denied authorized representatives to access resident records. It is alleged that both the resident’s daughter and Ombudsman asked for residents records and were denied access to the records by facility. S6 admitted to LPA denying access to incident reports to Ombudsmen explaining that she was following legal advice from facility attorney. The daughter of R14 sent several emails requesting R14 medical record beginning on Oct 4th, 2022, and the facility did not provide them within 24 hours as required by regulations. Therefore, based on the information gathered and the interviews conducted the allegation has been deemed Substantiated.

Allegation: Staff did not report incident to appropriate parties. It is alleged that the facility failed to report two incidents to appropriate parties. The facility failed to report the incidents to the Ombudsman when the Ombudsman requested incident reports. The Ombudsman had received authorization to act on behalf of resident and should have been able to review and obtain copies of the incident reports dated 09/25/2022 and 09/26/2022. Finally, on 10/25/2022 the two incident reports were emailed to Ombudsman Tam dated 09/25/2022 and 09/26/2022. LPA noted that the SIR from incident on 09/26/2022 was dated on 09/25/2022. CCL has a record of SIR from 09/25/2022 but no internal record that SIR from 09/26/2022 was reported to CCL. Facility could not provide proof that SIR dated 09/26/2022 was faxed over. Therefore, based on the information gathered and the interviews conducted the allegation has been deemed Substantiated.

Based on LPA's observations, records reviewed, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated.



Per California Code of Regulations, Title 22, deficiencies will be cited on the LIC9099-D.

An exit interview was conducted with Supervisor Anne Graves and a copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20230314164113
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/19/2023
Section Cited
CCR
87468.1(2)
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87468.1 (2) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(2) To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment.
This requirement is not met as evidenced by:
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Administrator to self certify that there is proper observation of Resident's when assistance is needed.
Administrator to submit to Licensing a Staff Training in dealing with observation of residents and any changes physically, emotionally, and mentally. Plan to be submitted by 12/19/2022.
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Facility staff failed to properly observe R14 that resulted in fall with injury and failed to properly assess R14 after fall.
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Type B
12/19/2023
Section Cited
CCR
87468.1(a)(8)
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Personal Rights
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs.
The requirement is not met as evidenced by:

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Administrator shall ensure that family and responsible party of residents are informed in a timely manner. The licensee will write a letter to CCL explaining how this will be remedied and read section Title 22 section 87468.1(a)(8).
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Facility failed to communicate with family/responsible party promptly and appropriately after incident on 09/25/2023. Family was not notified about incident until the following day.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20230314164113
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/19/2023
Section Cited
CCR
87211(a)(1)(d)
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87211(a)(1)(d) Reporting Requirements. (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.

The requirement is not met as evidenced by:
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The administrator will review Title 22 Regulations, Section 87211 on Reporting Requirements, and submit a written plan detailing how facility will ensure that incidents are reported to the CCL office as required according by the Regulation. The administrator must also conduct in-service training to all staff in reference to Reporting Requirements and provide a copy of names and signatures of all staff in attendance of training. POC is due to CCL by 12/19/2022
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During the course of the investigation, LPA discovered that a special incident report was not submitted by the facility for incident for Resident #14 on 09/26/2022 according to Title 22 Reporting Requirements. Incident reports dated 09/25/2022 and 09/26/2022 were not provided to Ombudsman until 10/25/2022
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5