191500609-7-21-2021-28-AS-WSHO-C6V5BA-20210914194824

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191500609
Report Date: 07/21/2021
Date Signed: 07/21/2021 03:09:44 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
06/30/2021 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210630154541

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: 157	DATE:	07/21/2021
		UNANNOUNCED	TIME BEGAN:	10:36 AM
MET WITH:	Administrator, Priscilla Gaytan		TIME COMPLETED:	03:20 PM

ALLEGATION(S):

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Staff did not assist resident with medications as needed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Vasallo conducted a complaint visit to investigate the allegations listed above. LPA met with Administrator, Priscilla Gaytan and explain 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 and staff schedule. During the initial visit Interviews were conducted with 9 residents and and 2 staff. On 7/16/21, 2 additional residents and 7 additional staff were interviewed. 1 additional staff was interviewed today. Facility was toured including first floor, second floor and garden area.

The investigation revealed the following: 5 out of the 11 residents interviewed indicated they have missed as needed medication or pain medication or the medication has been delivered to residents late. Residents reported waiting 1 to 2 hours sometimes to receive the medication. Residents believe the facility is short staffed because of the long response time by staff and the fact that residents have seen staff work double shifts often.
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: 07/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

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-20210630154541

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: 07/21/2021

NARRATIVE

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Staff members interviewed included Licensed Vocational Nurses (LVNs), Med Techs., caregivers, kitchen staff, maintenance and housekeeping. 7 out of the 10 staff interviewed reported the facility is short staffed and especially with the Med Techs. It was reported at times there have been 1, 2 or 3 Med Techs. in the PM shift for 158 residents. Med Techs. have to inventory the medication, watch the call light system that residents press for help, pass medication to individual rooms, and provide treatments to many of the residents. Many staff reported often working overtime and working double shifts multiple times a week. Staff interviewed admitted medication has been provided to residents late because of the shortage of staff and admitted some residents have not been provided with the required treatments.

Based on interviews conducted and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 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: 07/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210630154541

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: 07/21/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/22/2021 Section Cited CCR 87465(a)	1 2 3 4 5 6 7	Incidental Medical and Dental Care : (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:(5) The licensee shall assist residents with self-administered medications as needed.	1 2 3 4 5 6 7	Administrator is in the process of interviewing staff. Administrator has hired 3 additional med techs since early July. Med Techs are still in training. Facility will submit staffing plan by tomorrow.
	8 9 10 11 12 13 14	Deficiency was evidenced by the following: 5 out of the 11 residents interviewed indicated they have missed medication or the medication has been delivered late. 7 out of the 10 staff interviewed reported the facility is short staffed. Staff is working overtime and double shifts. Staff confirmed medication has been late and some treatments have been missed.	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: 07/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

LIC9099 (FAS) - (06/04)

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