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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603710
Report Date: 06/04/2024
Date Signed: 06/04/2024 12:29:09 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
05/31/2024 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240531152939
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:
06/04/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lisa Gomez, ManagerTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff do not give residents medication as prescribed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Glenn Trueman conducted the initial complaint investigation for the allegation listed above. LPA arrived unannounced and met with Lisa Gomez, Manager. The purpose of the visit was discussed.
During the visit today, LPA obtained copies of the staff roster and resident roster.
Interviews with Lisa Gomez, Manager and Staff S1 were conducted from 10:15 AM to 10:45 AM.
Interview was conducted telephonically with Staff S2 at 10:50 AM.
Interviews were conducted with Residents R1-R6 from 11:10 AM to 11:55 AM.
LPA toured the medication room and reviewed medication records for R1-R6.
In regards to the allegation Staff do not give residents medication as prescribed, based on interviews conducted, medication review and information gathered it was revealed in review of medication for R1-R6 that all medication was given as prescribed and R1-R6 did not miss any doses.
Review of pain medication showed that all doses were given as prescribed.
Interviews with R1-R6 who all stated that Staff S2 does a great job and they have never missed a dose.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2024
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-20240531152939
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: 06/04/2024
NARRATIVE
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R1-R6 all stated they have not observed S2 not giving anyone their medication and that it is always given per physician's directions. 1 resident who takes an inhaler stated that Staff S2 has never given more than 2 puffs as prescribed by the doctor and gives it the way she is suppose to.
R1-R6 all stated that Staff S2 does not bully anyone and does her job.
Spoke with staff who stated that there have been no complaints against Staff S2.
Also stated that they will look at the MAR's Log on the computer and if eligible will get the pain med. Order will be for either every 6 hours or 8 hours and only if not eligible would a resident get Tylenol.
All staff stated they follow doctor's orders and don't give any medication that is not prescribed.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with Manager Lisa Gomez.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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