191500609-3-26-2024-28-AS-FFIS-D5C2GH-20240516172312

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 03/26/2024
Date Signed: 03/26/2024 03:01:35 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
03/20/2024 and conducted by Evaluator Valeria Maldonado

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240320152703

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: 127	DATE:	03/26/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Priscilla Gaytan- Assistant Administrator		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Staff did not provide adequate supervision resulting in resident speaking to another resident in an inappropriate manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) V. Maldonado made an unannounced initial complaint visit at 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 rosters, and the following documents for Resident#1-2 (R1-R2): Facesheet, Physician's Report, Needs and Services Plan, and incident reports for the month of March 2024. LPA also conducted interviews with Residents#1-9 (R1-R9) and Staff#1-5 (S1-S6).

The investigation revealed the following:

(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: 03/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

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-20240320152703

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: 03/26/2024

NARRATIVE

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Regarding allegation: Staff did not provide adequate supervision resulting in resident speaking to another resident in an inappropriate manner.
It is alleged that on 3/18/24, while waiting for breakfast in the dining room, R1 was playing music loudly on a personal device, to which R2 got upset by, and resulted in R2 yelling profanities at R1. Per staff interviews, (7) of (7) of staff stated that R1 and R2 do not get along well. (5) of (7) staff interviewed admitted to the incident of a verbal altercation between R1 and R2 occurring, but denied it occurred due to to lack of adequate supervision. Staff stated that if they witnessed the altercation, they would have intervened and reported it to management. Per S1 and S2, R1 informed S1 of the incident and wanted to have the concern addressed. S1 addressed the concern by speaking with R1 and R2, and asking them to speak to each other to try to resolve the matters, but both residents declined. Per S1, R1 declined to stop playing their music during meal times and will continue to purposely do it "to prove a point." Per resident interviews, (3) of (10) residents admitted the verbal altercation occurred. R3 stated to have witnessed the altercation between R1 and R2, however, R1-R3 stated no staff were present to witness it. R1 stated to have been playing R1's music from their electronic device in the dining room, when suddenly, R2 got up and began shouting profanities at R1 solely for playing R1's music. R2 did not previously ask R1 to lower the music or turn it off. R2 admitted to cursing at R1 for having their music playing loudly and stated that it is "disrespectful" to play music while others are eating. R3 corroborated to the incident occurring this way. R3 stated that R2 was shouting "nasty and dirty" profanities at R1 and felt uncomfortable at the things R2 told R1. R3 stated that R1 stayed quiet while R2 shouted these things at R1. R1 then spoke up and told R2 something in R1's defense. (5) of (9) residents interviewed stated that R1 and R2 have had problems with one another for a few years now. Residents stated that management is aware of this and have tried to intervene, but the issues are ongoing for unknown reasons. Per the incident report obtained, dated 3/18/24, the incident involving R1-R2, and concerns addressed were reported to licensing on 3/20/24.

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.
Per California Code of Regulations, Title 22, no deficiencies were observed or cited during today's visit.

Exit interview was conducted 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: 03/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

LIC9099 (FAS) - (06/04)

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