191500609-1-29-2021-28-AS-MVAO-C2AQ3F-20210421114840

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 01/29/2021
Date Signed: 01/29/2021 03:18:02 PM

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
01/28/2021 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210128132729

FACILITY NAME:	SAN DIMAS RETIREMENT CENTER		FACILITY NUMBER:	191500609
ADMINISTRATOR:	FERNANDA KEY		FACILITY TYPE:	740
ADDRESS:	834 WEST ARROW HIGHWAY		TELEPHONE:	(909) 599-8441
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	343	CENSUS: 161	DATE:	01/29/2021
		UNANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Fern Key, administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Questionable Death

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vasallo initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Fern Key, administrator.

The investigation consisted of the following: Conducted telephone interview with administrator, Staff #1 (S1), Staff #2 (S2), Staff #3 (S3), Resident #1 (R1), and Resident #2 (R2). Conducted a virtual tour of the first and second floor and R1's bedroom. LPA also reviewed recent death reports.

The investigation revealed the following: It's alleged R1 passed away at the facility of unknown causes. R1's bedroom was virtually toured and R1 was observed in the room. R1 was later interviewed in private via telephone. R1 reported he/she enjoys living in the facility and has no issues with staff or residents. R2 was interviewed and reported that he/she thought R1 had passed away at the facility. Continued on 9099C.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2021

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-20210128132729

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: 01/29/2021

NARRATIVE

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Some of the staff interviewed reported that R2 was telling people that R1 had passed away at the facility. It was reported that R1 and R2 were acquaintances at one point, but are no longer. It was confirmed today that R1 is safe and currently living in the facility.

This agency has investigated the complaint alleging questionable death. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.

A telephonic exit interview was conducted with Fern Key, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2021

LIC9099 (FAS) - (06/04)

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