198602870-7-29-2020-28-AS-MVAO-BS6SZ8-20200804141845

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602870
Report Date: 07/27/2020
Date Signed: 07/29/2020 10:10:13 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
07/22/2020 and conducted by Evaluator Tony Vasallo

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200722112619

FACILITY NAME:	BROOKDALE SAN DIMAS		FACILITY NUMBER:	198602870
ADMINISTRATOR:	KNEEDY-CAYEM, KARA		FACILITY TYPE:	741
ADDRESS:	1740 SAN DIMAS AVENUE		TELEPHONE:	(909) 394-0304
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	131	CENSUS: 77	DATE:	07/27/2020
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Wellness Director, Tashia DeCorse		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Resident is being financially abused by staff members.

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 Wellness Director, Tashia DeCorse.

LPA conducted telephone interview with the administrator and conducted a virtual tour of the facility. LPA also requested and obtained copies of resident and staff rosters via email.

The investigation revealed the following: Administrator was inteviewed and indicated that Resident #1 (R1) is not a resident of the facility. LPA reviewed the resident rosters for the assisted living and the skilled nursing facility next door. LPA confirmed R1 is not a resident of the assisted living building and is a resident of the skilled nursing facility.

Continued on 9099C.

Unfounded

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: 07/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2020

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-20200722112619

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: 07/27/2020

NARRATIVE

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This agency has investigated the complaint alleging resident is being financially abused by staff members. 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.

A telephonic exit interview was conducted with Tashia DeCorse, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:	DATE: 07/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2020

LIC9099 (FAS) - (06/04)

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