191500609-12-4-2023-28-AS-FFIS-CZK2JX-20240116162703

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 12/04/2023
Date Signed: 12/04/2023 04:14:00 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/29/2023 and conducted by Evaluator Valeria Maldonado

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231129140105

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:	12/04/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Priscilla Gaytan- Assistant Administrator		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff did not ensure resident had a clean mattress.
Resident’s toilet was in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) V. Maldonado made an unannounced complaint visit to the facility for the purpose of investigating the above-mentioned allegations. During today's visit, LPA Maldonado met with Assistant Administrator, Priscilla Gaytan, and explained the purpose for the visit.

During today's visit, LPA Maldonado obtained a copy of the resident and staff roster, conducted a tour of the physical plant, and requested a copy of any recent plumbing invoices for repairs in the last month. LPA also obtained a copy of Resident# 1 (R1) Facesheet and Physician's Report, and conducted interviews with Residents# 1-10 (R1-R10) and Staff# 1-4 (R1-R4).

The investigation revealed the following:
Regarding allegation: Staff did not ensure resident had a clean mattress.
It is alleged that when R1 was moved to a new room, a clean mattress was not provided. (4) of (4) staff interviewed denied the allegation. They stated that some residents bring their own furniture when they move in and some prefer the furniture that the facility. (Report continued on LIC9099-C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

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-20231129140105

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SAN DIMAS RETIREMENT CENTER	FACILITY NUMBER: 191500609
	VISIT DATE: 12/04/2023

NARRATIVE

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Staff stated that any furniture that may be dirty, in disrepair, or in bad conditions are disposed of. During the inspection of R1's room, LPA observed R1's bed to have all the required linens, the mattress was in good repair and did not appear to be dirty. LPA also observed that R1's bed had a memory foam topper. Per R1, R1's family purchased it for additional comfort, however R1 stated to prefer R1's family purchase a new mattress altogether for R1. (6) of (10) residents could not corroborate the allegation.

Regarding allegation: Resident’s toilet was in disrepair.
It is alleged that on 11/26/23 and 11/27/23, R1's toilet was clogged and was in disrepair, and R1 had to use a garbage bag over a pail as a toilet. (4) of (4) staff interviewed denied the allegation. Per S3, R2 reported there was water leaking from the ceiling above R2's toilet (dates unspecified). S3 went to inspect and discovered that R1's restroom above R2's restroom was causing the leak. Upon repair, the leak in R2's restroom stopped. But, R1 did not report R1's toilet being in disrepair when S3 repaired the water leak. (3) of (4) staff stated that later that day, R1 reported R1's toilet was not flushing and appeared to be backing-up. Per interview with R1, R1 denied having to use a garbage bag over a pail as a toilet. The investigation revealed that R1 had access to the common bathroom, which was down the hall from R1's room. However, R1 chose not to use the common bathroom. R1 reported the toilet was fixed that same day by maintenance and a towel was pulled out from the toilet’s plumbing, which was causing the toilet to clog. Per staff, a copy of the repair invoice could not be provided, as there was no work order completed due to the issue being an emergency/priority. (6) of (10) residents interviewed could not corroborate the allegation.

Based on LPA's observations and interviews conducted, there was not enough supportive evidence to concur with the reported allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

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

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023

LIC9099 (FAS) - (06/04)

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