191500609-11-7-2023-28-AS-FFIS-D35TXB-20240307140648

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 11/07/2023
Date Signed: 11/07/2023 01:32:06 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
10/30/2023 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231030152936

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: 133	DATE:	11/07/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Administrator Priscilla Gaytan		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Staff are committing tax identity theft using resident's personal information.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jose Villalobos conducted an unnanounced complaint investigation visit for the allegation above. LPA met with Administrator Priscilla Gaytan and the purpose of the visit was discussed.

On todays visit, LPA Villalobos conducted the following: toured the physical plant, interviewed staff #1-#8 (S1-S8) , Interviewed residents #1-#13 (R1-R13), and collected a copy of the staff and resident roster. The investigation revealed the following:

In regards to the allegation "Staff are committing tax identity theft using resident's personal information" it was alleged that a staff of the facility was claiming a resident on their taxes as a dependent. (8) of (8) Staff interviewed denied the allegation or any knowledge of it. (13) of (13) Residents interviewed could not corroborate the allegation...

Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

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-20231030152936

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: 11/07/2023

NARRATIVE

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Interviews with staff and residents do not show that there has been an incident of staff claiming a resident on their taxes as a dependent. File review did not show that there were any reports regarding the incident. LPA did not observe that the facility keeps tax filings for staff. LPA was not provided with proof that there is a staff member claiming a resident on their taxes as a dependent. Based on interviews, files reviewed, and observations conducted, there was not enough supportive evidence to concur with the reported allegation. 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.

Exit Interview conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC9099 (FAS) - (06/04)

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