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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603710
Report Date: 05/21/2024
Date Signed: 05/21/2024 03:56:49 PM

Substantiated


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
05/17/2024 and conducted by Evaluator Valeria Maldonado
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240517121025
FACILITY NAME:BAYSHIRE SAN DIMASFACILITY NUMBER:
198603710
ADMINISTRATOR:COLEMAN, CHADFACILITY TYPE:
741
ADDRESS:1740 S SAN DIMASTELEPHONE:
(909) 394-0304
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:119CENSUS: 53DATE:
05/21/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Heather O'Neel- Health Services DirectorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Licensee does not ensure the facility has an administrator present a
sufficient number of hours to adequately manage facility.
Staff are preventing resident from receiving telephone calls.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced initial complaint visit to the facility for the purpose of investigating the above mentioned allegations. LPA Maldonado met with Health Services Director, Heather O'Neel and explained the purpose of the visit. Executive Director, Chad Coleman arrived shortly after to assist with the visit.

During today's visit, LPA Maldonado obtained a copy of the resident and staff roster, and obtained pertinent documents for Staff#1-2 (S1-S2). Interviews were also conducted with Staff#1-9 (S1-S9) and Residents#1-5 (R1-R5).

The investigation revealed the following:

(Report continued on LIC9099-C...)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
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 3
Control Number 28-AS-20240517121025
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: 05/21/2024
NARRATIVE
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Regarding allegation: Licensee does not ensure the facility has an administrator present a
sufficient number of hours to adequately manage facility.
It is alleged that facility operational concerns are not being addressed due to the administrator never present at the facility. Per interviews conducted with staff, (6) of (9) staff corroborated the allegation. (2) of (6) staff stated the listed administrator is present at the facility once every (2) to (3) weeks. (4) of (9) staff stated the administrator has only been present at the facility twice since the facility was licensed, on April 1, 2024. Per resident interviews, (3) of (5) residents corroborated the allegation. Residents stated to not know who the listed administrator is and stated that S2 is actually the administrator.

Regarding allegation: Staff are preventing resident from receiving telephone calls.
It is alleged that the facility is not answering the telephone during their listed hours of operations to reach residents in care. Per staff interviews, (4) of (9) staff corroborated the allegation. Staff stated that the receptionist is responsible for answering the telephones and unlocking the facility front doors at 8:00am. However, the receptionist is not always on time, so the phone calls get answered upon staff arrival. Per resident interviews, (1) of (5) residents corroborated the allegation. Residents stated the receptionist is responsible for unlocking the front doors and answering the phones at 8:00am, however the receptionist is late and this is not being done timely. R1 stated to have opened the front door for a visitor last week because they were knocking and there was no staff present at the front desk to answer it.

Based on LPA's observation and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated.

Per California Code of Regulations, Title 22, deficiencies were observed and will be cited on LIC9099-D.

An exit interview was conducted and a copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240517121025
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/24/2024
Section Cited
CCR
87405(a)
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87405 Administrator - Qualifications and Duties
(a)The administrator...shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section.
This requirement was not met as evidenced by:
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Licensee will submit a written plan to the Licensing department on how they will ensure the administrator will be on the premises a sufficient amount of hours to ensure operational needs/concerns are addressed. Plan to be emailed to LPA by POC due date.
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Based on interviews conducted, the Licensee failed to ensure the administrator is at the facility a sufficient amount of hours to address operational concerns of the facility, which poses a potential Health, Safety, or Personal Rights risk to persons in care.
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Type B
05/21/2024
Section Cited
CCR
87468.1(a)(14)
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87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(14)To have reasonable access to telephones, to both make and receive confidential calls...
This requirement was not met as evidenced by:
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Licensee will submit a written plan to the Licensing department on how they will ensure the facility telephones are answered regularly during business hours to meet resident needs. Plan to be emailed to LPA by POC due date.
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Based on interviews conducted, the Licensee failed to ensure the facility telephone is answered during normal business hours so that residents may be contacted, which poses a potential Health, Saftey, or Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Valeria Maldonado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3