191500609-2-20-2025-28-AS-CGUZ-DE3TDD-20250220133810

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191500609
Report Date: 02/20/2025
Date Signed: 02/20/2025 01:38:20 PM

Document Has Been Signed on 02/20/2025 01:38 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	SAN DIMAS RETIREMENT CENTER		FACILITY NUMBER:	191500609
ADMINISTRATOR/ DIRECTOR:	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:	02/20/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:30 AM
MET WITH:	Administrator Priscilla Gaytan		TIME VISIT/ INSPECTION COMPLETED:	01:50 PM

NARRATIVE

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Licensing Program Analyst (LPA) Christian Gutierrez conducted the annual inspection using the Compliance and Regulatory Enforcement (CARE) tools. LPA met with Administrator Priscilla Gaytan and explained reason for visit. The facility is licensed to serve (343) older adults, ages 60 and over. There is a fire clearance approved for (343) non-ambulatory residents. It has an approved Dementia Care Plan and a Hospice Waiver approved for (30) residents. There are currently (10) residents receiving hospice care. LPA observed the physical plant, reviewed residents' medications, observed food supply, and reviewed staff and resident files.

Resident bedrooms were randomly chosen for review. Each bedroom has a bed, linen, dresser, light, and sufficient closet space. The resident bathrooms have the required grabs bars and non-skid mat. The hot water was between 105.3 - 107.8 degrees which is within the required 105 - 120 degrees. Cleaning supplies are inaccessible to residents. The kitchen was inspected. There is sufficient perishable and non-perishable food. All the appliances are clean and seem to be operating properly. The common areas include the activity room, dining room, and patio areas. These areas are clean and have the required furniture. There are no firearms or weapons stored at the facility. The facility does not have a swimming pool or bodies of water on the premises There is a shaded seating areas for the residents located around the facility. Passageways and exits are free of obstruction.

LPA reviewed 10 resident records to confirm emergency contact is updated and residents have health screenings on file. 10 staff records were reviewed to confirm health screenings with TB, CPR training and fingerprint clearances. LPA reviewed 5 residents' medications. Medications are documented properly and stored in a locked office.

Per California Code of Regulations, Title 22, there were no deficiencies observed during the visit. Exit interview held. A copy of the report was provided to the Administrator.

SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/24/2025 08:34 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 02/20/2025 05:04 PM

Created By: Christian Gutierrez On 02/20/2025 at 01:24 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/25/2025
	Plan of Correction
1 2 3 4	Cited in error.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Tony Vasallo

LICENSING EVALUATOR NAME:

Christian Gutierrez

LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025

LIC809 (FAS) - (06/04)

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