191500609-12-10-2024-28-AS-TVAO-DBWUKS-20241213143938

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 12/10/2024
Date Signed: 12/10/2024 02:31:36 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
12/05/2024 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20241205092915

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: 125	DATE:	12/10/2024
		UNANNOUNCED	TIME BEGAN:	09:16 AM
MET WITH:	Priscilla Gaytan, Administrator		TIME COMPLETED:	02:37 PM

ALLEGATION(S):

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Staff did not allow the resident to fully participate in planning their care.

INVESTIGATION FINDINGS:

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LIcensing Program Analsyt (LPA) Alberto Lopez made an unannonced visit to investigate the above alegation. LPA was greeted by Staff Bianca Castillo and Admiistrator Priscilla Gayton arived a short time later and asssited with the visit.

The investigation consisted of Interviews with four (4) staff (S#1-S#4) and ten (10) residents (R#1-R#10) LPA reviewed and obtianed resident and staff rosters, current medication list for R1, medication list dated 2022 for R1, and Physician's report for R1.

The investigation revealed: Allegation Staff did not allow the resident to fully participate in planning their care. It is alledged that that his doctor prescribed a second psychiatric medication against resident wishes.

(Continued 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

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-20241205092915

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: 12/10/2024

NARRATIVE

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(Continued from 9099)

LPA interviewed four staff (4) and four (4) of four (4) staff denied the allegation. LPA interviewed ten (10) residents and nine (9) of ten (10) were not able to corroborate the allegation.

S1 stated that facility has always includes residents in their care planning. S1 stated resident brought this issue to S1 in November 2024 and told S1 that R1 did not want to take the medication and S1 told resident that R1 has right to refuse any medication and S2 called R1 MD to discontinue the medication.

LPA interviewed R1 and R1 stated R1 does not recall specific details, but stated that R1 was given a psychotropic medication, that S2 identified as Amitriptyline, since 2022 that R1 never agreed to. R1 stated R1 did not recall the medication name but R1 stated that it is on a list in R1 file. R1 stated that when R1 started getting the medication back in 2022, R1 asked S2 what the medication was for and was told it was for ulcers and stomach pain. R1 stated R1 did not have ulcers. R1 stated to LPA that R1 does not have clear recollection of details and continued to take the medication until one day R1 decided to take R1 list of medications to a local pharmacy and was told what Amitriptyline was for. R1 asked S1 for it to be discontinued and it was discontinued by his physician. R1 was inconsistent in R1 statements and could not provide any evidence to support the allegation that staff lied to R1.

S2 stated R1 was already prescribed Amitriptyline medication before S1 even began work at facility which was three years ago. S2 denied ever telling R1 that Amitriptyline was for pain and ulcers. S2 stated S2 told R1 that Amitriptyline was for depression. S3 denied ever telling R1 anything about Amitriptyline. S3 stated it was never discussed with resident because resident did not bring it up to S3. There is no evidence that staff lied to resident.

Based on interviews, most residents stated they participate in their care plan and know what medications they take and the reason they take them. There is insufficient evidence to substantiate this allegation.

Based on statements and interviews conducted with staff, residents, and review of client file, there was not enough supportive evidence to concur with the reported allegations. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

LIC9099 (FAS) - (06/04)

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