191500609-4-30-2024-28-AS-FFIS-D4VTDT-20240502143850

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 04/30/2024
Date Signed: 04/30/2024 03:15:36 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
04/29/2024 and conducted by Evaluator Valeria Maldonado

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240429151719

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: 125	DATE:	04/30/2024
		UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Priscilla Gaytan- Assistant Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Facility is not ensuring that resident's transportation needs are being met while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) V. Maldonado made an unannouced initial complaint visit to the facility for the purpose of investigating the above-mentioned allegation. 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, and the following records for Resident# 1 (R1): Facesheet, Physician's Report, and Needs and Services Plan. LPA also conducted interviews with with Staff#1-4 (S1-S4) and Residents#1-5 (S1-S5).

The investigation revealed the following:

Regarding allegation: Facility is not ensuring that resident's transportation needs are being met while in care.
It is alleged that R1 requires transportation services to get to medical appointments due to R1's ambulatory status, however, R1 requests a large vehicle for transportation and does not get it, resulting in R1 missing medical appointments due to not feeling safe.

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: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

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-20240429151719

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: 04/30/2024

NARRATIVE

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Per staff interviews, (4) of (4) staff denied the allegation. They stated S2 assists with transportation arrangements and always requests for a larger vehicle, per R1's request. However, the transportation service sometimes sends what they have available. And if a smaller vehicle arrives, R1 refuses the service and misses medical appointments. Staff stated that on 4/29/24, transportation was arranged for R1 for a medical appointment. When a smaller van arrived, R1 refused the transportation. Staff stated that R1 has a manual wheelchair which could fit in the smaller van and R1 could be transported, but R1 refuses to use it as R1 claims it does not work well. S2 stated to have requested a bigger vehicle when arranging transportation, however transportation services stated they provide what they can. Per R1's Appraisal and Physician's Report dated 7/27/23, R1 does not require assistance with transferring/propelling in wheelchair. Per interview with R1, R1 admitted to refusing the transportation on 4/29/24 as R1 did not feel safe going in the smaller van. R1 states to hit their head going over bumps and returns in pain due to too much motion in the small van. R1 stated S2 promised R1 to get a bigger van for R1's medical appointments, however this is the second time this occurs. Per resident interviews, (4) of (5) residents denied the allegation. Residents interviewed stated that S2 assists them with arranging transportation services and have never had issues. Residents stated that once they are aware of their appointments, they inform S2 of it and their transportation is always arranged for the dates and times they need it.

Based on the information obtained during the investigation, interviews with staff, residents, review of resident files and LPA's observation, the investigation did not reveal any evidence to support the allegation mentioned above.

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 allegation is Unsubstantiated.

An exit interview was conducted and 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: 04/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2024

LIC9099 (FAS) - (06/04)

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