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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603710
Report Date: 05/30/2024
Date Signed: 05/30/2024 01:24:57 PM

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
05/21/2024 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240521095500
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:
05/30/2024
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Lisa Gomez, Manager TIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Facility is in disrepair resulting in leaks.
Staff does not ensure facility carpet is clean and sanitized.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced complaint investigation regarding the above allegations. LPA met with Manager, Lisa Gomez who assisted with the visit.

Regarding the allegation that : Facility is in disrepair resulting in leaks. The investigation consisted of tour of facility, including memory care, interviews with Staff #1 - Staff #4, and Resident #1 - Resident #6. LPA did not observe any leaks during facility tour. Staff interviewed stated that there are no leaks in the facility. Staff indicated that if any leaks are reported or observed, maintenance staff will repair it right away. Residents interviewed did not corroborate the allegation. Six out of six residents stated that they have not observed any leaks in the facility.

Regarding the allegation that : Staff does not ensure facility carpet is clean and sanitized. The investigation consisted of tour of facility, including memory care, and interviews with Staff #1 - Staff #4, and Resident #1 - Resident #6.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
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 2
Control Number 28-AS-20240521095500
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: 05/30/2024
NARRATIVE
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Staff interviewed stated that they do ensure that the carpet is clean and sanitized. Residents interviewed did not corroborate the allegation. Six out of six residents stated that the staff frequently clean the carpet.

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.

Exit interview conducted, and a copy of the report was provided to Ms. Gomez.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Angelica Rea
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2