198603710-7-26-2024-28-AS-WSHO-D87PFZ-20240816111731

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603710
Report Date: 04/16/2024
Date Signed: 07/26/2024 11:42:36 AM

Unsubstantiated

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
04/11/2024 and conducted by Evaluator Nune Margaryan

COMPLAINT CONTROL NUMBER: 28-AS-20240411122938

FACILITY NAME:	BAYSHIRE SAN DIMAS		FACILITY NUMBER:	198603710
ADMINISTRATOR:	COLEMAN, CHAD		FACILITY TYPE:	741
ADDRESS:	1740 S SAN DIMAS		TELEPHONE:	(909) 394-0304
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	119	CENSUS: 54	DATE:	04/16/2024
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Heather O'Neel		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility in disrepair
Facility staff do not provide meals of the quality necessary
Laundry room does not have adequate supplies
Facility does not have a qualified administrator

INVESTIGATION FINDINGS:

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***This is an amended report which supersedes the original report dated 04/16/24. The purpose of this report is to remove confidential information. The amendment to the report does not affect or change the findings on this complaint***.
Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced complaint investigation visit regarding the above allegations. LPA Margaryan met with Health Services Director (HSD), Heather O'Neel who assisted with the visit. Purpose for the visit was explained.

During today's visit, LPA Nune Margaryan obtained a copy of the resident and staff roster, copy of the facility menu, Personnel Records and Administrator Certificates for the facility Administrator Chad Coleman and Health Services Director (HSD), Heather O'Neel. LPA toured the facility including the kitchen, dining room, laundry rooms and randomly chosen residents rooms. Interviewes condacted with HSD Heather O'Neel , Staff #1 - Staff #5 (S#1 - S#5) and Resident #1 - Resident #7 .(R#1 - R#7).
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Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024

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-20240411122938

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: BAYSHIRE SAN DIMAS	FACILITY NUMBER: 198603710
	VISIT DATE: 04/16/2024

NARRATIVE

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Regarding the allegation: Facility is in disrepair. it was alleged that " Place is in disrepair”. Staff interviewed denied the allegation. Staff stated that if anything is in disrepair, they put online maintenance/ work order, and the maintenance person will repair it in a timely manner. LPA toured the facility including randomly chosen residents rooms and observed that facility is in a good condition. All interviewed residents stated that everything works in their rooms and not aware of facility being in disrepair.

Regarding the allegation: Facility staff do not provide meals of the quality necessary. It was alleged that "Kitchen doesn’t offer adequate food". Interviewed staff and residents denied the allegation. LPA obtained a copy of the facility menu, and reviewed facility food supply. LPA observed a variety of food available and a sufficient quality. LPA toured the facility kitchen and observed an ample supply of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA observed bread, grains, meats, fruits, vegetables, eggs, juice, milk, and snacks in the kitchen / refrigerator / freezer. Staff and residents interviewed stated that residents can request an alternate meal if they don't want what is being served. Interviewed staff indicated they have not received any complaints about food/meal. Interviewed residents had no concerns about quality of food/meal.

Regarding the allegation: Laundry room does not have adequate supplies. It was alleged that "Laundry room isn’t equipped with supplies". Interviewed Staff denied the allegation. Health Services Director (HSD) and Staff # 4 denied the allegation stating that facility never runs out of the laundry supplies. LPA toured the laundry rooms and observed that each laundry room has a laundry detergent / soap dispenser, and they are full. Several large gallons of laundry detergent / soap observed in the main laundry room located at the first floor. LPA also observed boxes of plastic bags that staff use to separate the resident’s dirty and clean clothes, and different kind of laundry / cleaning supplies. Interviewed residents stated that they are not aware of laundry supplies at the facility.

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NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240411122938

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: BAYSHIRE SAN DIMAS	FACILITY NUMBER: 198603710
	VISIT DATE: 04/16/2024

NARRATIVE

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Regarding the allegation: Facility does not have a qualified administrator. It was alleged that "Administrator doesn’t qualify for managing". Chad Coleman is the administrator of the facility and on this position since 04/01/24. LPA reviewed the administrator file and observed that Chad Coleman has a Bachelor’s Degree, which meets the educational requirements for the administrator. He has an experience providing residential care to the elderly since 2019. He has an active Administrator Certificate, which expired on 05/10/2025. HSD O'Neel mentioned that she also has Administrator certificate for RCFE, and she is designated person in case of administrator absence (Copy of LIC308 was provided). She has (2) years completed of college, which meets the educational requirement of (2) years and has experience in providing residential care to the elderly since 2018. She currently has an active Administrator Certificate, which expired on 12/08/2024.

Based on interviews, records review and observations the investigation revealed: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

An exit interview was conducted with HSD Heather O'Neel, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2024

LIC9099 (FAS) - (06/04)

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