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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603710
Report Date: 06/13/2024
Date Signed: 06/13/2024 04:47:09 PM

Substantiated


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
05/29/2024 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240529144857
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:
08:54 AM
MET WITH:Lisa Gomez - ManagerTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff does not ensure food service sanitation practices are followed
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent 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' and kitchen staff files, and obtained a copy of caregivers' job duties.

Regarding the allegation "staff does not ensure food service sanitation practices are followed", it is alleged that the caregivers in memory care do not have a food handlers card and they plate all the food in memory care, they do not use hair nets or have temperature logs.
(Continued to LIC 9099-C)
Substantiated
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 6
Control Number 28-AS-20240529144857
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
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Interviews with memory care caregivers revealed that they do plate the food in the memory care dining room and that they have to wear hairnets and gloves. They also stated they do not have a food handlers certification. During lunch, LPA observed that the food is cooked in the kitchen and then transported in a hot box food warmer to the memory care dining room. The caregivers were wearing hairnets and gloves when they were plating the food. There is no Title 22 regulation that state that caregivers need to have a food handlers certification, however per Title 22 Section 87411 Personnel Requirements they have to have on the job training in regards to principles of good nutrition, good food preparation and storage, and menu planning. LPA requested for proof of this training for the memory care caregivers and S1 checked the caregivers files and told the LPA that there was no such training in their files. There was a temperature log located at the top of memory care dining room refrigerator, but there is no Title 22 regulation that state that the facility needs to have a temperature log, however per Title 22 Section 87555(b)(23) it states "all readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures". The food was transported in a hot box and when the food was being served and the LPA observed that it was at an appropriate temperature. Furthermore, residents interviewed stated that the food is served at an appropriate temperature.

Based on interviews conducted, observation and documents reviewed, the preponderance of evidence standard has been met, therefore the allegation is found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D.

Exit interview held and a copy of the report and appeal rights 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 6
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
05/29/2024 and conducted by Evaluator Luis Mora
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240529144857

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:
08:54 AM
MET WITH:Lisa Gomez - ManagerTIME COMPLETED:
11:15 AM
ALLEGATION(S):
1
2
3
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9
Staff does not ensure hygiene items of general use are made available to residents
Staff does not ensure facility is kept free of mal odors of residents
Staff does not ensure toilets are kept in good repair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent 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' and kitchen staff files, and obtained a copy of caregivers' job duties.

Regarding the allegation "staff does not ensure hygiene items of general use are made available to residents", it is alleged that residents and staff are not receiving hand soap and paper towels. Staff and residents interviewed did not corroborate the allegation. LPA observed hand soap and paper towels in the residents room that were toured, staff office, and the common area restrooms.
(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: 3 of 6
Control Number 28-AS-20240529144857
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
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Regarding the allegations "staff does not ensure facility is kept free of mal odors of residents" and "staff does not ensure toilets are kept in good repair", it is alleged that the toilets in rooms 219, 241, 319, and 341 are not functioning and there is a rancid sewer odor coming from the drains and toilets of these rooms bathrooms. Staff interviewed denied the allegations. Residents interviewed could not corroborate the allegation. LPA observed the toilets to be properly functioning and did not smell any odors coming from the toilet or drains in all the rooms toured during this visit (152, 169, 183, 186, 219, 241, 319, and 341).

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: 4 of 6
Control Number 28-AS-20240529144857
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/27/2024
Section Cited
CCR
87411(d)(1)
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Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance: (1) Principles of good nutrition, good food preparation and storage, and menu planning.

This requirement is not met as evidenced by:
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Licensee is to comply with Title 22 Section 87411 at all times. Additionally, Licensee will provide training to memory care caregivers in regards to Title 22 Section 87411(d)(1) and submit proof of the training to Community Care Licensing Division (CCLD) by 06/27/2024.
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Based on interviews, observation and records, the licensee did not comply with the section cited above which poses a potential health, safety or personal rights risk to persons in care. Memory care caregivers do not have the training in regards to preparing and handling food.
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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: 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6