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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 02:38:29 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
05/24/2024 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240524124243
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:
09:07 AM
MET WITH:Lisa Gomez, ManagerTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Licensee did not complete an admission agreement for resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit regarding the above allegation. LPA discussed the purpose of the visit with Manager Lisa Gomez. Administrator Chad Coleman was interviewed telephonically.

The investigation consisted of: A physical plant tour of interior common areas and resident bedrooms was conducted.Staff (S1- S4), residents (R1- R8), and family (F1) Resident (R1 & R2's) file documents were reviewed. Copies of Residence and Care Agreement, Move In-Record, Physician's Report, Pre-placement Appraisals, Resident Care Evaluation Admission Appraisals, staff roster, and resident roster were obtained.


***See narrative summary on next page.***
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
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 3
Control Number 28-AS-20240524124243
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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Allegation: Licensee did not complete an admission agreement for resident. The complaint alleges that resident (R1) moved in to the facility on May 14, 2024 without a signed admission agreement. Resident (R2) moved in on 5/24/2024. Bayshire San Dimas was licensed on April 1, 2024. A total of two (2) new residents moved in after licensure. Record review revealed that R1 does not have signed Residence and Care Agreements on file. Resident (R2's) Residence and Care Agreement was electronically signed today, within the seven days following admission. Both residents (R1 & R2) did not know whether their responsible parties have signed the admission agreement. R1's responsible party stated that they received the admission agreement 1 week after R1 moved in, and has not signed the agreement because they had questions, and preferred to meet with staff prior to signing the agreement. R1's responsible party stated they plan to visit the facility today and will be signing the agreement. File review indicates that resident (R1's) Resident Care Evaluation (Appraisal) has not been completed; only sections A. [I- III] are filled out. Per Clinical staff interview, a thorough coordination of care has not been discussed or implemented by the clinical team. A total of eight (8) residents were interviewed, of which all stated they or their responsible parties have not signed Residence and Care Agreements for Bayshire San Dimas; however, 6 out of 8 residents moved in prior to the change of ownership. Administrator Chad Coleman and Manager Lisa Gomez acknowledged the facility failed to obtain signed copies of R1's admission agreement. There is sufficient evidence to corroborate the allegation.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A deficiency is being cited. See LIC 9099D.
Exit interview was conducted with Manager Lisa Gomez. A copy of the report and appeal rights was provided.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
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 3
Control Number 28-AS-20240524124243
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: 05/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/06/2024
Section Cited
CCR
87507(c)
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Admission Agreements. Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.
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Administrator agreed to obtain a signed copy of R1's Residence and Care Agreement.

Submit a copy of the agreement.
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This requirement was not met evidenced by:
Based on record review and interviews conducted findings indicate R1 moved in on May 14, 2024, and as of today the facility has not obtained a signed admission agreement, 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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

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

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