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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602870
Report Date: 05/27/2020
Date Signed: 05/28/2020 07:41:06 AM



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
05/22/2020 and conducted by Evaluator Tony Vasallo
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200522130814
FACILITY NAME:BROOKDALE SAN DIMASFACILITY NUMBER:
198602870
ADMINISTRATOR:KNEEDY-CAYEM, KARAFACILITY TYPE:
741
ADDRESS:1740 SAN DIMAS AVENUETELEPHONE:
(909) 394-0304
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:131CENSUS: 79DATE:
05/27/2020
UNANNOUNCEDTIME BEGAN:
09:44 AM
MET WITH:Asst. Administrator, Ryan WestTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Resident sustained unexplained fractures while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Vasallo initiated a complaint investigation for the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Ryan West, the assistant administrator.

LPA Vasallo requested copies of the resident roster and personnel roster to be emailed by 5/27/20. LPA obtained and reviewed the rosters. LPA also requested the roster for the Skilled Nursing Facility (SNF) next door to the facility along with SNF admission records. It was determined that the alleged victim, Resident #1 (R1) does not reside at this facility.

This agency has investigated the complaint alleging resident sustained unexplained fractures while in care. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2020
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-20200522130814
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: BROOKDALE SAN DIMAS
FACILITY NUMBER: 198602870
VISIT DATE: 05/27/2020
NARRATIVE
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A telephonic exit interview was conducted with Ryan West, and a hard copy was provided via email for signature.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 05/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 2