<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191500609
Report Date: 07/23/2024
Date Signed: 07/23/2024 04:18:47 PM


Document Has Been Signed on 07/23/2024 04:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CENTERFACILITY NUMBER:
191500609
ADMINISTRATOR:PRISCILLA GAYTANFACILITY TYPE:
740
ADDRESS:834 WEST ARROW HIGHWAYTELEPHONE:
(909) 599-8441
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:343CENSUS: 126DATE:
07/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Destiny Cazares, LVNTIME COMPLETED:
04:20 PM
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
Licensing Program Analyst (LPA) Galarza conducted a Case Management- Deficiencies visit due to observation made while investigating complaint control #: 28-AS-20240722091157. The purpose of the visit was explained to LVN Destiny Cazares.

LPA interviewed resident (R1) in their room and observed three (3) medication pill bottles on top of the side table next to the recliner. LPA asked the resident a series of questions to determine mental function status. The resident was not oriented to time, day of the week, and was unable to recall the names of prescribed medications and dosage times. The resident stated "I need help with my meds. I don't remember if I took them. Please help me."

LPA called LVN staff and the medications were removed from the resident's room. Per staff, medication management will be initiated and R1's responsible party will be notified. Staff shall follow-up with Primary Care Physician for change in condition.

Per Title 22, Division 6, Chapter 8, Article 08. Resident Assessments, Fundamental Services and Right 87465(h)(1)(B) Incidental Medical and Dental Care... Medications shall be centrally stored under the following circumstances: Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed.

Deficiency was cited.

Exit interview held with Destiny Cazares. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 07/23/2024 04:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/24/2024
Section Cited
CCR
87465(h)(1)(B)

1
2
3
4
5
6
7
Incidental Medical and Dental Care. Medications shall be centrally stored under the following circumstances: Any medication is determined by the physician to be hazardous if kept in the personal possession of the person for whom it was prescribed.
This requirement was not met evidenced by:
1
2
3
4
5
6
7
LVN staff removed medications from R1's room, and will begin managing R1's medications.
Administrator shall:
1. Submit written proof of correction and conduct staff training by tomorrow.
2. Notify responsible party of care plan changes
3. Follow-up with Primary Care Physician for change in condition
8
9
10
11
12
13
14
Based on observation during interview with resident (R1), 3 medications were observed on the resident's table next to the recliner. Resident stated they are confused and need help with medication management; resident could not recall the names or dosage times; which poses an immediate health and safety risk to the resident.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2