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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 11/03/2023
Date Signed: 11/03/2023 03:53:12 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
10/30/2023 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20231030155552
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: 134DATE:
11/03/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Patricia Gaytan TIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Staff stole resident's belongings.
Staff did not change resident's urine soaked bedding.
Staff did not ensure that fall risk measures were in place for the resident at the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wong conducted the “Initial 10-Day” visit to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Staff #1 Joanna Mariscal who allowed entry into the facility and was later met by Administrator Priscilla Gaytan who assisted with the visit.

The investigation consisted of the following: On the above date, LPA toured the facility (Memory Care Unit) and also interviewed 14 residents (R1-R14), administrator, seven staff (S1-S7) and Resident#1 (R1) daughter via telephone. LPA also obtained doucmnets include: resident and staff roster and R1's physician report, identification and emergency information, resident appraisal, individual service plan dated on 7/6/22 and 09/26/23 and incident reports for October, 2023.

(See LIC 9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
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-20231030155552
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: 11/03/2023
NARRATIVE
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The investigation revealed of the following: Allegation#1 "Staff stole resident's belongings" LPA interviewed 14 residents and 14 out of 14 denied the allegation and reported staff never stole their belongings. 12 residents out of 14 residents stated that they never lost anything in the facility. LPA interviewed staff and stated that no residents ever complained the staff stole their belongings and they did complete LIC621 when residents first moved into the facility.

Allegation#2 "Staff did not change resident's urine soaked bedding." LPA interviewed 14 residents, 12 out of 14 residents and denied the allegation and stated that the staff cleaned their room every day and changed their beddings every week or as needed. LPA interviewed the staff and denied the allegation and reported they changed and checked on the incontinence residents every two hours. Staff stated that they changed R1's beddings everyday or as often as needed. Staff reported R1 refused to be changed most of the time and caused soaked bedding but they would let housekeeping know immediately if they observed R1's bedding was soaked in wet. LPA toured residents' rooms in the facility and all the beddings and linens are clean.

Allegation#3 "Staff did not ensure that fall risk measures were in place for the resident at the facility." The administrator and LVN stated that although R1 is considered a fall risk resident, she is not a high risk for falls. She did not fall a lot and did not have any fall incidents lately. LPA also reviewed R1's incident reports and did not observe any fall incident for R1 in the past month. Administrator also reported their house doctor usually comes once a month and see R1 and the doctor knows R1 very well and they never recommended or suggested a hospital bed with bed side rail for R1 due to R1's condition.

Based on the documents reviewed, interviews conducted with staff and residents, the preponderance of evidence standard has 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.

Exit interview was conducted with Priscilla Gaytan Administrator and a copy of this report was provided.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
10/30/2023 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20231030155552

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: 134DATE:
11/03/2023
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Patricia Gaytan TIME COMPLETED:
04:20 PM
ALLEGATION(S):
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Facility is odoriferous.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wong conducted the “Initial 10-Day” visit to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Staff #1 Joanna Mariscal who allowed entry into the facility and was later met by Administrator Priscilla Gaytan who assisted with the visit.

The investigation consisted of the following: On the above date, LPA toured the facility (Memory Care Unit) and also interviewed 14 residents (R1-R14), administrator, seven staff (S1-S7) and Resident#1 (R1) daughter via telephone. LPA also obtained doucmnets include: resident and staff roster and R1's physician report, identification and emergency information, resident appraisal, individual service plan dated on 7/6/22 and 09/26/23 and incidents reports for October, 2023.

(See LIC 9099C for continuation)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20231030155552
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: 11/03/2023
NARRATIVE
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The investigation revealed of the following: Allegation "Facility is odoriferous." LPA toured R1's room in Room#19 from the memory care unit and when LPA stepped into R1's room, the room was immediately an overwhelming smell of both urine and mildew. According to the administrator and staff, its reported R1 requires total assistance from staff and R1 always refused to change and therefore the beddings were always soaked but staff did change R1's bedding at least once a day or as often as needed. Housekeeper indicated that they would open the window and spray the air refresher to prevent the smell of urine in R1's room.

Based on LPA's observation and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is 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 Administrator Priscilla Gaytan and a copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 28-AS-20231030155552
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: 11/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2023
Section Cited
CCR
87625(b)(3)
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87625 Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.

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The administraor will ensure the incontinent residents are kept clean and dry that facility remains free of odors from incontinence. The administaror will send the update care plan about R1 regarding about R1 refused to change and the plan how to keep R1's room free of odor from incontinence.
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The requirement was not met as evidenced by LPA's observation, LPA toured R1's room ( room#19 from Memory Care Unit) and when LPA opened the door, LPA smelled the urine in the room which posed a potential risk to residnets in care.
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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: David SicairosTELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5