191500609-5-8-2026-28-AS-LHIS-DUVRHA-20260609130201

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 05/08/2026
Date Signed: 05/08/2026 02:32:56 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
10/31/2025 and conducted by Evaluator Bennette Pena

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20251031163810

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: 112	DATE:	05/08/2026
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Priscilla Gaytan - Administrator		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Questionable death.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent visit in response to the above-mentioned allegation. LPA met with Priscilla Gaytan, Administrator and explained the reason for the visit.

The investigation consisted of the following: On 11/04/2025, LPA conducted a tour of the facility, including Memory Care. Assisted Living and common areas. LPA obtained a copy of the Staff and Resident rosters, Unusual Injury/Incident Reports/SIRs (06/26/2025), Death report and pertinent facility files and Resident #1 (R1) files. LPA interviewed Staff #1 (S1) - Staff #2 (S2). LPA did not observe any immediate Health and/or Safety concerns. Prior to today's visit, LPA obtained pertinent files for R1, including death certidicate.

On 05/04/2026, LPA obtained a copy of the Staff and Resident rosters, additional R1's files pertinent to the investigation. LPA telephonically reinterviewed Staff #1 (S1) - Staff #2 (S2) and interviewed Staff #5 (S5) - Staff #6 (S6). LPA also interviewed Staff #3 (S3), Resident #2 (R2) - Resident #11 (R11) in person. LPA made (3) attempts to interview Staff #4 (S4) but no response received. On 05/05/2026, LPA interviewed S4 on the phone.

During today's visit, LPA obtained a copy of the Staff and Resident rosters and delivered findings.
*****CONTINUED ON LIC9099-C*****

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026

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 2

Control Number 28-AS-20251031163810

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: 05/08/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The investigation revealed the following:

Allegation: Questionable death. It is alleged that facility’s neglect caused R1’s death because they did not check R1’s vital signs (oxygen levels, blood pressure, or blood sugar) adequately. According to information obtained, R1 was admitted to the facility on 05/04/2022, did not have a 1:1 care, was alert, and had been diagnosed with Dementia. After being examined by a doctor, R1 was moved from Memory Care to Assisted Living on 01/30/2024. On 06/25/2025, at approximately 6:30am, S4 assessed R1 due to a complaint of abdominal pain and constipation and then called the doctor for evaluation. At approximately 8:30am, S4 spoke with FM (R1’s responsible party) to give an update on R1’s condition and to ask if they would want to bring R1 to the hospital for further evaluation, but FM decided to do in-house treatment for R1 instead. Afterwards, S4 called the doctor over again who then gave R1 a prescription for a laxative and suppository.
All staff interviewed stated that R1 was placed on 1–2-hour checks. Staff stated they provided proper care to R1 by assessing pain, bowel movements, abdominal distension, palpation, vital signs monitoring and reporting to the physician, as well as kept an eye out for any changes in condition. When assessed, four (4) on-duty staff interviewed stated that R1 was alert, vital signs were stable and did not exhibit signs of distress. Staff decided to take R1 to the hospital after R1 had refused to take the prescribed medication, and the suppository failed to work. R1 refused to be taken to the hospital and signed the Refusal of Medical Attention form at 5:25pm. Staff contacted FM to get permission for the hospital transfer. At approximately 8:00pm, S6 contacted the non-emergency transportation service to take R1 to the hospital. FM was also contacted by S6 to report on R1's situation and condition. At 11:50pm, R1 was taken to the hospital by the non-emergency transportation service, and R1 passed away two (2) days later, on 06/27/2025. Staff interviews, medication records and chart notes revealed that they implemented appropriate interventions, checked vital signs frequently throughout the day, administered prescribed laxatives and monitored R1's symptoms.

Based on record reviews, reports and interviews gathered, the findings indicate that R1 had pre-existing health conditions and there was no physician’s order to monitor R1’s vital signs at regular intervals throughout the day or week. LPA obtained a copy of the Death Certificate that stated the immediate cause of death was Cardiopulmonary Arrest. The death has no indication of neglect, or lack of care and supervision. There is insufficient evidence to corroborate the allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted, and a copy of this report was provided to Priscilla Gaytan, Administrator.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 2