191500609-4-14-2021-28-AS-MVAO-C2AQYN-20210421123524

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 04/14/2021
Date Signed: 04/14/2021 02:49:28 PM

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
01/21/2021 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210121080245

FACILITY NAME:	SAN DIMAS RETIREMENT CENTER		FACILITY NUMBER:	191500609
ADMINISTRATOR:	FERNANDA KEY		FACILITY TYPE:	740
ADDRESS:	834 WEST ARROW HIGHWAY		TELEPHONE:	(909) 599-8441
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	343	CENSUS: 159	DATE:	04/14/2021
		UNANNOUNCED	TIME BEGAN:	09:49 AM
MET WITH:	Fern Key, Administrator		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Staff did not attend to resident's call for help
Staff did not assist resident to go see the facility doctor in a timely manner
Staff did not assist resident with baths
Staff practices are unsanitary when serving food to residents
Staff did not properly assist resident with medication
Staff burned resident while bathing

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vasallo initiated a subsequent complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Fern Key, administrator. The initial complaint visit was conducted on 1/29/21.

The investigation consisted of the following: During the initial tele-visit, interviews were conducted with administrator, 3 staff and 2 residents. A virtual tour of the first and second floor was also conducted. During the subsequent complaint visit additional interviews were conducted with 8 residents. A virtual tour was also conducted to test the hot water and call system from resident's room.

The investigation revealed the following: Allegation: Staff did not attend to resident's call for help. Staff interviewed deny the allegation. Residents interviewed indicated that staff do respond when they call the staff on the phone or use the call button in their room. During the virtual tour the call system was tested and was functioning properly. Based on the information obtained, the allegation is unsubstantiated. Continued on 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021

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-20210121080245

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: 04/14/2021

NARRATIVE

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Allegation: Staff did not assist resident to go see the facility doctor in a timely manner. Staff interviewed deny the allegation. Staff indicated they go to residents rooms and assist them to get ready to go see the doctor. Residents interviewed also indicated staff assist with seeing the facility doctor. No one reported witnessing staff refuse to assist a resident. Based on the information obtained, the allegation is unsubstantiated.

Allegation: Staff did not assist resident with baths. The complainant could not provide a date, time or staff involved regarding this allegation. Staff interviewed indicated they do assist residents with baths. Staff indicated some residents refuse baths and they report the refusal to management. Residents interviewed stated that staff do assist with baths up to twice a week if they need assistance. Residents admitted that they have refused assistance with baths if the staff members arrive to the residents' room later in the day. The facility has 2 bath aides in the morning and companion aides are also expected to assist with bathing if needed. There is insufficient evidence to prove this allegation. Therefore, this allegation is unsubstantiated.

Allegation: Staff practices are unsanitary when serving food to residents. Staff interviewed deny the allegation. LPA has observed staff members deliver trays during virtual tours and the food and drinks are covered and staff are wearing gloves and masks. Residents interviewed also indicated the food is served properly and they have no issues the way the food is served. No one reported observing unsanitary food service and no one has reported feeling ill because of the food. Based on the information obtained, the allegation is unsubstantiated.

Allegation: Staff did not properly assist resident with medication. The complainant could not provide a date, time or staff involved regarding this allegation. It's alleged staff have given the resident(s) medication late. Staff interviewed deny the allegation. Residents interviewed also did not corroborate the allegation and residents indicated they have had no issues with their medications. No one reported their medications being administered late and no one has been hospitalized because of medication issues. Based on the information obtained, the allegation is unsubstantiated.

Allegation: Staff burned resident while bathing. The complainant could not provide a date, time or staff involved regarding this allegation. Complainant indicated the alleged victim did not sustain any injuries and it allegedly occurred one time. Staff interviewed deny the allegation. Residents interviewed indicated there is no issue with the hot water. The water was tested during today's visit and it was 105 degrees which is within the required range of 105 - 120 degrees. Based on the information obtained, the allegation is unsubstantiated.
Continued on 9099C.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210121080245

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: 04/14/2021

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	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. A telephonic exit interview was conducted with Fern Key, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021

LIC9099 (FAS) - (06/04)

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