191500609-12-12-2024-28-AS-RORN-DCPPH4-20250107101920

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 12/12/2024
Date Signed: 12/12/2024 05:20:56 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
12/09/2024 and conducted by Evaluator Daniel Konishi

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20241209140014

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:	12/12/2024
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Anne Graves, LVN Supervisor		TIME COMPLETED:	05:25 PM

ALLEGATION(S):

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Staff are refusing to allow resident to have access to their personal belongings.
Staff did not safeguard resident's personal belongings.
Staff did not accord privacy to resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Daniel Konishi conducted an Initial 10-Day complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit with (Licensed Vocational Nurse) LVN Supervisor, Anne Graves.

The investigation consisted of: LPA conducted interviews with LVN Supervisor, Anne Graves, Staff #1 (S1) to Staff # 5 (S5), and Resident #1 (R1) to Resident #13 (R13). LPA also interviewed the Assistant Administrator, Karen Meacham, and Staff #6 (S6) over the phone on today’s visit. LPA also requested copies of Staff and Resident Rosters. LPA requested R1 personnel file document: Identification and Emergency Information, Face Sheet, Physician's Report, Admission Agreement, Client/Resident Personal Property and Valuables, House Rules, Facility notes. LPA also requested staff training logs.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Daniel Konishi	TELEPHONE: 323-981-3978
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

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-20241209140014

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 12/12/2024

NARRATIVE

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The investigation revealed the following: Allegation: Staff are refusing to allow resident to have access to their personal belongings. According to the allegation, staff will provide access to the personal belongings when R1’s room is fixed to the staff’s liking. It is alleged that R1’s personal belongings (toiletries, pajamas, clothing, bedding, shoes) were taken out of R1’s room by facility staff and stored in another room in which facility staff is refusing to allow R1 access to R1’s belongings due to the staff stating that R1’s room is cluttered. Based on interview of the Assistant Administrator, LVN Supervisor, and six (6) out of six (6) staff all stated that the facility must follow safety protocol and ensure that residents and staff are kept safe from injuries, fire hazards and trips. All staff interviewed also indicated and provided information confirming to the LPA that R1’s room was unsafe, unsanitary, and had no clear passageway in case of emergencies. Interviews conducted with twelve (12) out of thirteen (13) residents denied the above allegation and have never had been in a situation where they were refused access to their personal belongings due to the room being cluttered. Based on record review, facility’s House Rules were provided to R1 and signed on the date of admission: 06/28/2024 which states ‘use the unit as your private residence and will maintain it in a clean, sanitary and orderly condition.’ The House Rules also states ‘Residents may not maintain their units in a manner that creates or presents a fire hazard, including but not limited to the storing of belongings in an excessive or unsafe manner, the obstruction of exists or passageways, or the storing of flammable or combustible materials. Based on interviews conducted, LPA was provided information that indicated that R1 was given a key to the room where R1’s personal belongings are and R1 has access to the personal belongings. S6 stated that R1 was allowed access to R1’s personal belongings on 12/06/2024. Based on interviews conducted with facility staff, and facility residents, there was not enough supportive evidence to concur with the reported allegation.

Allegation: Staff did not safeguard resident's personal belongings. It is alleged that when R1 was out of the facility, staff entered her room and took R1’s personal belongings and stored in another room strewn with other resident’s belongings in a mixed and disorganized way. Interviews conducted with twelve (12) out of thirteen (13) residents denied the above allegation and stated that they believe their personal belongings are kept safe. However, based on the observation, R1 is provided a key in a locked room so the personal belongings are secure. Per resident file reviews, staff maintain records of the resident’s personal belongings and have a facility theft and loss program document on file. LPA also requested and reviewed monthly training logs on topics of HIPPA, Resident Rights, Resident Dignity on file from 02/08/2024 to 08/06/2024. Based on interviews conducted with facility staff, and facility residents, there was not enough supportive evidence to concur with the reported allegation.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Daniel Konishi	TELEPHONE: 323-981-3978
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20241209140014

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 12/12/2024

NARRATIVE

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Allegation: Staff did not accord privacy to resident. It is alleged that a facility staff went into the resident’s room without consent from R1 for the purpose of taking personal belongings to create a safe environment and clear passageway. Based on staff interviews, R1 was received multiple verbal warnings to clean her room. The reason was due to safety concerns regarding the clutter and no clear pathway inside the room. During today’s visit, LPA observed the room and a clear pathway. LPA observed there was minor improvements of cleanliness but room does appear cluttered. Interviews conducted with the Assistant Administrator, LVN Supervisor and six (6) out of six (6) staff revealed that the facility staff deny the above allegation and respect resident’s privacy. Interviews conducted with twelve (12) out of thirteen (13) residents all deny the allegation and stated that they believe to be accorded privacy from the staff. LPA also reviewed monthly training logs on topics of HIPPA, Resident Rights, Resident Dignity on file from 02/08/2024 to 08/06/2024. Based on interviews conducted with facility staff, and facility residents, there was not enough supportive evidence to concur with the reported allegation.

Based on LPA observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be UNSUBSTANTIATED.
Exit interview was conducted with LVN Supervisor, Anne Graves and a copy of this report was provided.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Daniel Konishi	TELEPHONE: 323-981-3978
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024

LIC9099 (FAS) - (06/04)

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