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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603710
Report Date: 03/28/2024
Date Signed: 03/28/2024 04:55:56 PM

Document Has Been Signed on 03/28/2024 04:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:BAYSHIRE SAN DIMASFACILITY NUMBER:
198603710
ADMINISTRATOR:COLEMAN, CHADFACILITY TYPE:
740
ADDRESS:1740 S SAN DIMASTELEPHONE:
(909) 394-0304
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 114CENSUS: 58DATE:
03/28/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Scott Kirby- Applicant/LicenseeTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) V. Maldonado made an announced visit at the facility for the purpose of conducting a Pre-Licensing Inspection, using the Compliance and Regulatory Enforcement (CARE) Tool, to evaluate the facility. LPA Maldonado met with Applicant, Scott Kirby, and explained the purpose for the visit.

This is a Change of Ownership. Applicant has requested to operate as a Residential Care Facility for the Elderly. Per the application received, applicant has requested a fire clearance to serve (114) older adults, ages 60 and over, of which (104) will be non-ambulatory, and (10) will be bedridden. Applicant has also requested to care for residents with dementia, and has a pending Dementia Care Plan. The dementia unit currently has delayed egress. The department has not received an approved fire clearance yet. Per the applicant, a Hospice Waiver was requested to care for (20) residents. However, LPA did not receive any documentation from the Centralized Application Bureau indicating it has been approved. There are currently (12) residents receiving hospice services. The facility is a three-story building. The assisted living section has 90 resident bedrooms and has a separate dementia unit with 23 resident bedrooms. An Infection Control plan has been submitted and approved by the department. The facility has an active and current liability insurance policy on file.

During today's visit, LPA Maldonado conducted a tour of the physical plant with Applicant, observed the facility food supplies, reviewed (5) resident medications, (5) resident files, and (5) staff files. LPA inspected random bedrooms on all (3) floors. Resident bedrooms were observed to have the required furniture, sufficient lighting, and closet/storage space. Resident bathrooms and shared shower rooms were equipped with required grab bars and non-skid mats. The hot water was tested and measured between 113*F-117*F, which is in compliance. Food supplies was observed and was sufficient as required. Fire extinguishers were observed throughout, with current inspections and were fully charged. All sharps and cleaning supplies/toxins were observed to be locked and inaccessible to residents in care. There is an electric fireplace in the lobby/dining room covered with a screen. The last fire drill was conducted on 2/16/24. Auditory devices were observed at all entrances/exits of the memory care unit and were operational.
(Report Continued on LIC9099-C)
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: BAYSHIRE SAN DIMAS
FACILITY NUMBER: 198603710
VISIT DATE: 03/28/2024
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The signal system in resident bedrooms were tested and operational. There is sufficient indoor and outdoor activity space for residents. There are (2) courtyards in assisted living and an enclosed patio in memory care with shaded seating areas. Evacuation chairs were observed at each stairwell. Water fountains were observed in the courtyards of assisted living and are inaccessible. All required postings were observed throughout the facility. Sufficient additional linens/towels were observed. The laundry areas are kept locked and inaccessible to residents at all times. Resident files and staff files were reviewed and observed to be complete with all required documentation. Resident medications were reviewed and observed to be documented properly and given as prescribed.

During the pre-licensing inspection, items were observed which do not comply with applicable laws and regulations. The following items must be corrected:
  • An approved Fire Clearance has not been received by the department


Applicants have been notified to contact LPA Maldonado once the corrections have been made. The physical plant was not cleared during today's inspection, due to the corrections needed.

Component III orientation has been waived by applicant today, due to being completed for another licensed facility within the last year.

An exit interview was conducted with applicant and a copy of this report has been furnished. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024
LIC809 (FAS) - (06/04)
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