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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 01/07/2025
Date Signed: 01/07/2025 02:41:50 PM

Substantiated


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
12/31/2024 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241231151353
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: 129DATE:
01/07/2025
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Annadelle Padua and Priscilla GaytanTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not distribute resident's medication as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted a visit to investigate the above allegations. LPA met with Annadelle Padua/S-1 and discussed the purpose of today’s visit.

During this visit, LPA obtained a copy of the staff and resident rosters, interviewed Staff #1 (S-1) through Staff #6 (S-6), interviewed Resident #1 (R-1) through Resident #5 (R-5), obtained a copy of the as needed (PRN) medication log administered on 12/31/24, a list of residents that frequently request as needed (PRN) medication and reviewed R-1’s file and obtained relevant documentation. LPA attempted to interview Resident #6 (R-6) and Resident #7 (R-7). Both R-6 and R-7 refused to be interviewed.

Refer to LIC LIC9099C for the continuation of this report.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
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 3
Control Number 28-AS-20241231151353
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: 01/07/2025
NARRATIVE
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Allegation: Staff did not distribute resident's medication as prescribed. It has been alleged that on 12/31/24, R-1 called staff and requested R-1’s pain medication and was not provided with the medication. (4) out of (6) interviewed staff indicated that they recalled R-1 recently requesting R-1’s pain medication but were unable to provide the date nor time of the request as there are numerous residents that request their as needed (PRN) medications daily. (2) out of (5) interviewed residents indicated that they have recently requested their as needed (PRN) medications and were not provided with their request. Documentation reviewed revealed that on 12/31/24, R-1 was provided with Baclofen 10mg and Ibuprofen 600mg at 3:01 A.M. and 8:17 A.M. for pain. Per documentation, on 12/31/24, R-1 was not provided with another dose of the above noted medications. Per R-1’s physician’s order, both Baclofen 10mg and Ibuprofen 600mg are to be administered TID (every 8 hours) for pain as needed. R-1’s medication administration log indicated that both medications were administered in less than (8) hours and the log does not include the “reason” nor “result” of the administered medication.

Based on interviews conducted and document review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

Deficiency is being cited according to California Code of Regulations, Title 22. Refer to LIC 9099D.

Exit interview, appeal rights and a copy of this report was provided to Priscilla Gaytan.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20241231151353
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/08/2025
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-
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Administrator to submit a written statement which includes a plan on staff training pertaining to PRN medication administration to LPA Irra by POC date 01/08/25.

Administrator to ensure staff training in this subject is completed within (2) weeks.
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administered medications as needed. This standard is not met at evidence by: Per medication log, R-1 was provided with both PRN medications in less than (8) hours (ordered for TID/every (8) hours) and the log does not include the “reason” nor “result” of the administered medication.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3