<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603710
Report Date: 06/13/2024
Date Signed: 06/13/2024 04:50:59 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
06/06/2024 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240606082847
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: 54DATE:
06/13/2024
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Lisa Gomez - ManagerTIME COMPLETED:
04:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are violating residents’ personal rights by telling them not to file complaints with CCLD
Staff did not treat resident with dignity and respect
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Luis Mora conducted an unannounced initial complaint visit to determine the validity of the above-mentioned allegations. LPA met with Lisa Gomez (Manager) and explained the reason for the visit.

The investigatiion consisted of the following: LPA Mora requested for copies of the staff and resident rosters, and interviewed the Manager, Staff 1 - Staff 9 (S1 - S9), and Resident 1 - Resident 8 (R1 - R8). LPA also toured rooms 152, 169, 183, 186, 219, 241, 319, and 341, staff office, kitchen and common area restrooms. LPA reviewed memory care caregivers' files and obtained a copy of caregivers' job duties.

Regarding the allegation "staff are violating residents’ personal rights by telling them not to file complaints with CCLD", it is alleged that management is telling staff, residents, and family not to file complaints or concerns with state. (Continued to LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
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-20240606082847
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BAYSHIRE SAN DIMAS
FACILITY NUMBER: 198603710
VISIT DATE: 06/13/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The manager stated that this is not true and that they have the CCLD complaint hotline poster in the main lobby and anyone is free to call CCLD to file complaints. LPA confirmed that the CCLD complaint hotline poster is posted in the main lobby where is visible. Staff and residents interviewed denied the allegation.

Regarding the allegation "staff did not treat resident with dignity and respect", it is alleged that the manager is mean to the residents. The manager denied this allegation and stated she is respectful towards all residents. Staff and residents interview did not corroborate the allegation.

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 held and a copy of the report was provided
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Luis Mora
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2