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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 06/20/2024
Date Signed: 06/20/2024 02:41:01 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
06/18/2024 and conducted by Evaluator Erik Zaragoza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240618092225
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: 124DATE:
06/20/2024
UNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Jessica Camacho - ReceptionistTIME COMPLETED:
02:55 PM
ALLEGATION(S):
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Illegal eviction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an initial complaint visit to investigate the allegation listed above. LPA met with Jessica Camacho, recptionist for the facility, and explained the purpose of the visit. Administrator Priscilla Gaytan arrived shortly thereafter.

The investigation consisted of the following:LPA interviewed Staff #1 - 5 (S1 - S5), Witness #1 (W1), obtained the resident roster, and also obtained the Physician's Report, Appraisal, FACE Sheet, Physicians Orders, and a Resident Discharge Summary for R1.

The investigation revealed the following: In regards to the allegation "Illegal Eviction," it is alleged the facility illegally evicted R1 by discharging them to a hospital without issuing a 30-day eviction notice, and then refused to accept the resident back into the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik ZaragozaTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
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 2
Control Number 28-AS-20240618092225
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: 06/20/2024
NARRATIVE
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During interviews with the staff members, four (4) out of four (4) did not corroborate the allegation. S1 stated that R1 was never served an eviction notice, but rather was transported to Norwalk Community Hospital on 6/14/2024 for a psychological evaluation due to R1's need for a higher level of care, which the Primary Care Physician (PCP) of R1 agreed with. S1 stated that R1 had been having increasing behavioral issues, including hitting and scratching the caregivers who attempt to assist R1 with their Activities of Daily Living (ADLs). S1 explained that R1 has since been discharged to a Skilled Nursing Facility known as Maywood Health and Wellness Center, and that discharge paperwork for R1 from San Dimas Retirement Center was signed by R1's POA on 5/19/2024. Other staff interviewed stated that R1 did exhibit increasing agitation, refused assistance with their ADLs, and that it was taking multiple caregivers at a time to assist R1. Upon record review LPA observed that there was a Physician's Order from R1's PCP that R1 requires a higher level of care. LPA also observed that on 6/19/2024, R1's POA signed a Resident Discharge Summary for R1.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. 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.

Exit interview held, and a copy of this report was provided.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik ZaragozaTELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2