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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603710
Report Date: 05/21/2024
Date Signed: 05/21/2024 04:03:46 PM

Document Has Been Signed on 05/21/2024 04:03 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/
DIRECTOR:		COLEMAN, CHADFACILITY TYPE:
741
ADDRESS:1740 S SAN DIMASTELEPHONE:
(909) 394-0304
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 119CENSUS: 53DATE:
05/21/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Heather O'Neel- Health Services DirectorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) V. Maldonado made an unannounced visit to the facility for the purpose of issuing citations. LPA Maldonado met with Health Services Director, Heather O'Neel and explained the purpose for the visit.

During a complaint visit to the facility on 5/21/24, LPA Maldonado reviewed facility files for Staff#1-2 (S1-S2). During the file review, LPA discovered that although S1 has an administrator certificate# 6065866740, valid 1/10/23 - 5/10/25, S1 does not meet the qualifications of being an administrator for a Residential Care for the Elderly (RCFE). Per interview with S1, S1 stated to have never worked in an RCFE before or provided care to residents. LPA Maldonado also discovered that S2 does not have appropriate criminal background clearance and has been working at the facility since 4/01/24. Per interview with S2, S2 confirmed to have been hired and working here since 4/01/24.

Per California Code of Regulations, Title 22, deficiencies were observed and cited on the LIC9099-D page.
Additionally, immediate Civil Penalties in the amount of $500 were issued.

An exit interview was conducted and copy of the appeal rights were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Valeria Maldonado
LICENSING EVALUATOR 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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/21/2024 04:03 PM - It Cannot Be Edited


Created By: Valeria Maldonado On 05/21/2024 at 03:00 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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 A
05/22/2024
Section Cited
CCR
87355(e)(1)

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87355 Criminal Record Clearance
(e) All individuals subject to a criminal record review...shall prior to working...in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the Department...
This requirement was not met as evidenced by:
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S2 will be removed from the facility immediately and Licensee will submit proof of clearance prior to allowing S2 back to the facility. Proof to be emailed to LPA once obtained.
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Based on interview and record review, the Licensee failed to ensure that S2 had appropriate criminal record clearance prior to working at the facility, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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Type B
05/31/2024
Section Cited
CCR87405(f)

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87405 Administrator - Qualifications and Duties
(f) The administrator in facilities licensed for fifty (50) or more shall have two years of college; at least three years experience providing residential care to the elderly; or equivalent education and experience as approved by the licensing agency.
This requirement was not met as evidenced by:
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Administrator to submit proof to reflect that Administrator meets the qualifications noted in this regulation or provide new qualified administrator with the specified qualifications noted above to LPA Irra by POC due date.
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Based in interview and record review, the Licensee failed to ensure the listed administrator has appropriate qualifications to manage the facility, which poses a potential Health, Safety, 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.
SUPERVISOR'S NAME:Fernando Fierros
LICENSING EVALUATOR NAME:Valeria Maldonado
LICENSING EVALUATOR 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


LIC809 (FAS) - (06/04)
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