191500609-12-12-2023-28-AS-RORN-CZBP5G-20240109100044

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 12/12/2023
Date Signed: 12/12/2023 02:58:49 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
07/24/2023 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230724124405

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: 132	DATE:	12/12/2023
		UNANNOUNCED	TIME BEGAN:	10:01 AM
MET WITH:	Anne Graves, LVN Supervisor		TIME COMPLETED:	02:57 PM

ALLEGATION(S):

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Resident fell while in care sustaining in fracture.
Staff did not seek medical attention to resident in a timely manner.
Staff did not respond to resident in a timely manner.

INVESTIGATION FINDINGS:

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LPA made subsequent visit to complete investigation for the above allegations. LPA met with LVN Supervisor
Anne Graves and discussed purpose of the visit.

LPA reviewed and obtained copies of staff and resident rosters, R15 Physician’s report for Residential Care facilities, R15 hospital discharged summary. Incident reports dated 07/19/2023 (2) LPA interviewed five Staff S#1-S#5 (S1-S5) and15 residents R#1-R#15 (R1-R15)
The investigation revealed:

Allegation: Resident fell while in care sustaining in fracture. It is alleged that resident sustained a fracture while in care.

(continued on 9099C)

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: 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)

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Control Number 28-AS-20230724124405

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 R15 and R15 explained that R15 was using the bathroom on 07/19/2023 at around 7:30- 8:00am and was attempting to back up coming out of restroom to sit on wheelchair and the wheelchair didn’t have the brakes on and it roll backed and R15 hit the floor injuring R15 hip and ribs. R15 stated it was not facility staff neglect or fault that R15 fell. R15 admitted that wheelchair brakes were broken and R15 should have never been using it since R15 had other wheelchairs R15 could have used. There is no evidence that facility was neglectful or was at fault for R15 fall.

Allegation: Staff did not seek medical attention to resident in a timely manner. It is alleged that facility staff did not seek medical attention to client after fall.

S3 stated she was first to assist R15 in the am and was alerted to R15 needing help by residents in the garden who congregate by resident’s room in the smoking area, and she assessed R15 and asked R15 if R15 would accept going to hospital. R15 refused to go to hospital at that time. S4 who was in training and shadowing S3 also stated that R15 refused to go to hospital when initially offered. R15 was offered pain medication at the time and according to S3, it was provided. R15 at first stated that R15 did not refused but then stated that R15 does not remember the events of the day and that R15 may have refused to go to hospital initially. S5 stated that his shift begins in the afternoon and that when he met up with R15 around 3:00-3:30pm, R15 asked to go to hospital and S5 contacted S3 and R15 was transported to San Dimas Community Hospital that afternoon. S5 stated that R15 never mentioned to him that he had asked staff to call 911 or to be taken to hospital earlier. There is not enough evidence to support that facility failed to provide medical attention to resident in timely manner.

Allegation: Staff did not respond to resident in a timely manner. It is alleged that resident used the call light to get help and that S6 did not respond and get help for R15 for at least 30 minutes.

LPA interviewed 5 staff and all 5 denied the allegations. R15 stated he pulled the call light at around 7:30 – 8:00 am and that it took a long time for front desk to get R15 assistance. S3, S4 and S5 stated that resident never mentioned he used call light and that no one from the front desk informed them that resident needed assistance. The front desk staff S6 was not available to answer questions and did not return LPA calls and no longer employed at facility. Facility does not keep logs of call light request. There is no evidence to substantiate this allegation.

Based on the documents reviewed, interviews conducted with staff and residents, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 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)

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