191500609-10-1-2024-28-AS-LHIS-D9UNBD-20241008101858

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 10/01/2024
Date Signed: 10/01/2024 04:37:50 PM

Substantiated

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
07/22/2024 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240722091157

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:	10/01/2024
		UNANNOUNCED	TIME BEGAN:	09:11 AM
MET WITH:	Priscilla Gaytan, Administrator		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Staff left a resident unattended.
Staff did not ensure a resident's alert device was properly operating.
Staff did not properly report an incident involving a resident.
Staff overcharged a resident for services not received.
Resident sustained unexplained injury while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit with Administrator Prisicilla Gaytan.

An initial complaint visit was conducted on 7/23/2024, consisting of a physical plant tour of the interior common areas and resident (R1's) room. The call light system in R1's room was tested, and pictures of R1's injuries were taken. Staff (S1- S6) and resident (R1) were interviewed. Copies of the following documents were obtained: Resident (R1's) [Admission Record/Identification and Emergency Information, Residency Agreement, Individual Service Plan & Preferences, Physician's Reports [6/18/24 & 4/9/2019], Resident Appraisal, Head-to Toe Assesment dated 7/18/24, six (6) incident reports, Charting Notes, Plan of Operation/Fall Risk Plan, and staff and resident rosters were obtained. Photographs of R1's injuries were obtained. During today's visit, records were reviewed and a copy of the updated Residency Agreement "Addendum to Rental Agreement" and 7/17/24 staff assignment schedule were obtained, a physical plant tour of the AL and Memory Care Unit was completed, and residents (R2- R11), R1's authorized representative, and staff (S1 & S8) were interviewed.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024

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 7

Control Number 28-AS-20240722091157

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: 10/01/2024

NARRATIVE

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Allegation: Staff left a resident unattended. It was reported that 95 year old resident fell in the bathroom on 7/17/2024 between the hours of 10PM -11PM, and laid on the floor for hours until morning the next day. A total of 7 staff were interviewed. The staff person that was in charge of R1's care during the NOC shift on 7/17/24 no longer works at the facility; therefore, was not interviewed. According to staff interviews, resident (R1) was found on the floor the next day (7/18/2024) at approximately 7:30 AM. The resident returned to the facility the same day of the fall, after completing rehabilitation orders following a hip replacement surgery in June 2024. Based on observation, resident rooms have pull string signal system in the resident's room and bathroom, and also provide a hanging or wrist pendant to residents. Resident (R1) was wearing the signal system wrist pendant at the time of the fall. However, the wrist pendant was inoperable. The resident was not able to reach the signal pull strings in the room due to injuries. Caregiver responsibilities include checking on residents every 2 hours, or 30 minute to 1-hour checks after resident's return from the hospital because residents may be weaker or have changes in condition. A total of 11 residents were interviewed, of which 5 residents stated that NOC shift staff sometimes take 45 minutes to 1 hour to respond to signal system. On 7/23/2024, LPA tested R1's signal wrist pendant and it was not operable. The findings reveal that R1 fell and none of R1's attempts to receive assistance were answered, and staff did not check on the resident between the hours of 10 PM - 7:30 AM. Based on record review, there is no documentation that R1 was being checked more frequently after returning from the hospital, nor whether the NOC shift caregiver (S8) was aware that the resident had returned from the hospital. There is sufficient evidence to corroborate the allegation.

Allegation: Staff did not ensure a resident's alert device was properly operating. It is alleged that R1 was not able to receive staff assistance or medical attention in a timely manner after falling in the room. The resident attempted for hours to call staff for assistance by pressing the bracelet/watch pendant, but it was not working. On 7/23/2024, LPA tested the wrist pendant and confirmed it was not operating. Staff interviewed stated the signal pull strings in resident rooms and bathrooms work, but stated that some residents had been provided wrist or hanging neck pendants for use. However, staff stated that they failed to check on wrist/neck pendants regularly, and were unaware that they were not operable. Resident interviews revealed, that not all residents were given or use wrist/neck pendants, but had heard residents complain to Administration staff that the wrist/neck pendants were not operating properly. During both visits, the signal system was tested. It was observed that the Memory Care Unit signal system is separate from the Assisted Living area of the facility. This facility does not have signal system pagers that alert staff on duty when a resident requires assistance. Based on observation, there is sufficient evidence to corroborate the allegation.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 28-AS-20240722091157

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: 10/01/2024

NARRATIVE

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Allegation: Staff did not properly report an incident involving a resident. It is alleged that resident (R1's) authorized representative was not notified of the fall incident that occurred on 7/17/24, and discovered the next day 7/18/24, at approximately 7:30 AM, until later in the day after a Kaiser Permanente Physical Therapist (PT) visited the resident and observed bruises in knees, arms, and upper body. The PT notified facility nurses to call R1's MD. Based on record review, staff completed a "Head-to Toe Assessment" at 11:30 AM. LPA reviewed facility charting notes, and there was no documentation of R1's fall or notification to physician or responsible party. The incident report obtained does not list the time responsible party or MD were contacted. Once facility staff notified R1's MD, it was recommended that R1 be transported to the emergency room for x-rays. A total of 11 residents were interviewed, all stated that facility staff notify their responsible parties. However, in this case R1's responsible party was not notified right after they addressed the resident's fall. The resident's family received a call from staff notifying them that MD advised for the resident to be evaluated at the emergency room, many hours later after the fall incident. Staff protocol is to call facility nurse after fall, then paramedics, and after the medical emergency has been taken care LVNs are to notify family. There is sufficient evidence to corroborate the allegation.

Allegation: Staff overcharged a resident for services not received. It was reported that resident (R1's) authorized representative met with Administration staff the day (7/17/24) the resident returned to this facility after discharge from a rehabilitation facility. It was agreed that a new additional personal care rate in the amount of $550.00 would be charged for incontinence care, bathing assistance, escort assistance, and more frequent checks due to post surgery hospitalization, effective 7/17/2024. Staff stated that caregivers meet daily with LVNS to report changes in condition of the residents, but in this case when the resident returned to the facility they did not obtain discharge paperwork from the family. Administrator stated that staff began providing ADL assistance in April 2024 without charge when they observed decline, but family had not agreed to pay extra for the services. However, the findings indicate that family signed an Addendum to Rental Agreement for personal care the afternoon of 7/17/2024, with an understanding that R1 would be checked on more frequently than every 2 hours, because the resident returned from a higher level of care facility. Since, the resident fell the same day they returned to the facility and laid on the floor for hours, and after the authorized representative agreed to an increase in rate, there is sufficient evidence to corroborate the allegation. NOTE: Resident (R1's) authorized representative was refunded the pro rated personal care rate paid by the family.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 7

Control Number 28-AS-20240722091157

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: 10/01/2024

NARRATIVE

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Allegation: Resident sustained unexplained injury while in care. It is alleged that resident (R1) sustained a hip dislocation i.e the hip replacement came out of the socket, when the resident fell on 7/17/2024. According to information obtained, the fall resulted in multiple bruising/scrapes in knees, arms, chest, and throughout R1's body. Staff acknowledged observing bruising on knees and arms, but the Head-to-Toe Assessment did not document bruising on the arm or hip bruising/redness. LPA obtained an x-ray photograph of the injury caused by the fall. It shows the the metal socket completely dislocated. The resident had to undergo another hip replacement surgery as a result of the major injury. The resident never returned to the facility after the 2nd hip replacement surgery and was discharged from the facility on 8/30/24. There is sufficient evidence to prove R1's injuries were a result of neglect of care.

Based on interviews conducted, record review, and photographic evidence, the preponderance of evidence standard has been met, therefore the above allegation are found to be SUBSTANTIATED. Deficiencies are cited. See LIC 9099D.

An exit interview was conducted. A copy of this report and appeal rights will be provided via email and mailed to facility Administrator Priscilla Gaytan because of printing issues.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 28-AS-20240722091157

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/01/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/02/2024 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator agreed to submit a plan of correction that states staff responsibilities after residents return from higher level of care discharges, protocols in place, and proof of staff-in service training, which includes staff signatures. Submit written plan by tomorrow and proof of staff training by 10/4/2024.
	8 9 10 11 12 13 14	Based on interviews and records review, the findings indicate care staff did not conduct at the very least 2 hours checks after returning to the facility on 7/17/24, which resulted in R1 falling and laying on the floor unassisted for hours. This posed an immediate health and safety risk to the resident.	8 9 10 11 12 13 14
Type A 10/02/2024 Section Cited CCR 87303(i)(1)(C)	1 2 3 4 5 6 7	Maintenance and Operation. Facilities shall have signal systems .... All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: Identify the specific resident living unit.	1 2 3 4 5 6 7	Administrator agreed to: 1. Submit a written POC stating how the deficiency will be corrected by tomorrow. 2. Proof of staff in-service due 10/4/24. 3. Proof that the entire building's signal system, wrist/neck pendants were tested and are operational is due 10/4/24.
	8 9 10 11 12 13 14	Based on physical plant observations during the visit on 7/23/24, R1's signal wrist bracelet was not working. The resident relied on the wrist alert system, which was inoperable on 7/17/24. This posed an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14	***NOTE: LPA observed: 1.The Memory Care Unit has a separate signal system in place, with staff having to run to the signal system room when rooms cannot be identified. 2. Facility staff do not use signal system pagers.

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 Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 28-AS-20240722091157

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/01/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/04/2024 Section Cited CCR 87468.1(a)(8)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement was not met evidenced by:	1 2 3 4 5 6 7	Administrator agreed to provide in-service training regarding 87468.1 and provide written statement of how the facility will document responsible party contact when incidents occur, and/or there is a change in condition.
	8 9 10 11 12 13 14	This requirement was not met evidenced by: Based on record review and interviews conducted staff did not notify R1's responsible party of R1's fall incident (7/17/24), until late afternoon 7/18/24, after Kaiser PT staff notified LVNs of injuries observed, which posed a potential health and safety risk to R1.	8 9 10 11 12 13 14
Type B 10/04/2024 Section Cited CCR 87507(f)	1 2 3 4 5 6 7	Admission Agreements. The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met evidenced by:	1 2 3 4 5 6 7	Administrator agrees to submit proof of: 1. Staff training addressing protocols after residents return to the facility. 2. Change of condition procedures/documentation.
	8 9 10 11 12 13 14	Based on record review, on 7/17/24 R1's authorized representative met with staff and signed an Addendum to the Rental Agreement, that stated the resident would be receiving personal care services, and more frequent checks after return from a higher level of care facility.	8 9 10 11 12 13 14

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 Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 28-AS-20240722091157

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/01/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 10/02/2024 Section Cited CCR 87466	1 2 3 4 5 6 7	Observation of the Resident. The licensee shall ensure that residents are regularly observed for changes in physical...and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.	1 2 3 4 5 6 7	Administration staff agrees to submit a written plan that states how the deficiency was corrected by tomorrow, and proof of staff training by 10/4/2024.
	8 9 10 11 12 13 14	Based on interviews, photographs, and record review, the findings indicate that R1 dislocated the hip after falling on 7/17/24, and did not receive medical attention until late 7/18/2024, because staff did not perform a thorough body check, which posed an immediate health and safety risk.	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 Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024

LIC9099 (FAS) - (06/04)

Page: 7 of 7