191500609-7-16-2021-28-AS-WSHO-C62Q5U-20210819115230

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 07/16/2021
Date Signed: 07/16/2021 03:26:47 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
06/28/2021 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210628091908

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: 158	DATE:	07/16/2021
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Priscilla Gaytan, administrator		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Staff is not serving food of the quality necessary to meet the residents' needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vasallo conducted a subsequent complaint visit to investigate the allegations listed above. LPA met with administrator, Priscilla Gaytan and explained the reason for the visit. The initial complaint visit was conducted on 7/2/21.

The investigation consisted of the following: LPA obtained the resident and staff roster. Interviews were conducted with 11 residents and 8 staff. Facility was toured including first floor, second floor, garden area and kitchen.

The investigation revealed the following: All residents interviewed indicated the food is not good. Residents described the food as too salty, tough in texture, not well cooked, and the quality of the food is bad. Residents described the drinks served as watered down. Staff interviewed included medical technicians, caregivers, supervisors, cooks, and house keeping. Staff indicated they have received many complaints about the quality of the food served. Continued on 9099C.

Substantiated

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: 07/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021

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-20210628091908

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: 07/16/2021

NARRATIVE

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Some staff indicated they would not eat the food because it does not look good. Some staff felt the food is not healthy because residents are served bologna and other processed meats. Residents also felt they are not served healthy food. Residents confirmed they are served some processed meats and indicated they are served too many carbohydrates. Residents feel staff are cutting cost because of the low census of residents. Residents complained facility got rid of yogurt which was a healthy option in the morning. Kitchen staff confirmed they are no longer purchasing yogurt because of cost. The walk-in refrigerator and freezer were inspected. There were some fully cooked packaged meats such as pork patties. There were also bologna sandwiches. There were a couple of boxes of strawberries, celery, carrots, tomatoes and green onions. In the pantry there were cans of apple base, pineapple base, and prune juice which is added to water to make juice.

Based on interviews conducted with staff and residents and observations made, the allegation is substantiated. Deficiency issued on attached 9099D.

Exit interview held. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210628091908

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/30/2021 Section Cited CCR 87555(a)	1 2 3 4 5 6 7	General Food Service Requirements The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents and shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and .......	1 2 3 4 5 6 7	Administrator agreed to work with vendor to purchase other brands or different quality of foods. Administrator agreed to take resident suggestions to kitchen staff. Administrator will submit food receipts for the next 2 weeks.
	8 9 10 11 12 13 14	Deficiency was evidenced by the following: Residents described the food as too salty, tough in texture, not well cooked, and the quality of the food is bad. Residents described the drinks served as watered down. Staff confirmed they have received many complaints about the quality of the food and some indicated they would not eat the food.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021

LIC9099 (FAS) - (06/04)

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