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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603710
Report Date: 06/18/2024
Date Signed: 06/18/2024 01:36:25 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
06/10/2024 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240610142018
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: 52DATE:
06/18/2024
UNANNOUNCEDTIME BEGAN:
09:32 AM
MET WITH:Lisa Gomez, General Manager
Nadia Batista - Human Reseources Director
TIME COMPLETED:
01:43 PM
ALLEGATION(S):
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Staff are not meeting residents' dietary needs.
Staff do not provide adequate amount of food to residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced initial complaint visit regarding the above allegations. LPA met with Nadia Batista, Human Reseources Director and explained the reason for the visit. At 1pm, Lisa Gomez, General Manager arrived and assisted LPA with the investigation.

The investigation consisted of the following: LPA obtained copies of the staff and resident rosters, Weekly meal menu (May-June 2024), Always available menu, Residents' Dietary Communication list, and Dietitians information. During today’s visit, LPA along with Staff #3 (S3) toured the Kitchen, Dining room and inspected the food supplies. LPA interviewed Staff #1 (S1) – Staff #5 (S5) and Resident #1 (R1) – Resident #12 (R12).

The investigation revealed the following:
In regards to the allegation: “Staff are not meeting residents' dietary needs.”, it is alleged that staff is not following residents diets, that salt is added to no salt diet and food allergies are not being followed. Interviewed staff denied the allegation and stated that the food provided to residents meet their dietary needs.*****CONTINUED ON LIC9099-C*****
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
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-20240610142018
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: 06/18/2024
NARRATIVE
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S3 stated that the facility has a dietitian that reviews and approves their weekly menu or when there’s any changes to the menu. Staff indicated that med tech or charge nurse provides the kitchen staff a list of residents with special/restricted diet. Staff indicated that food requirements for residents are communicated to the kitchen staff verbally and also through a kitchen bulletin board. Interviewed staff stated that there is a board in the kitchen to pass notes among the kitchen staff and board also reflects Residents dietary needs (diabetic, no/low salt, food allergies, preference, requests, etc.). Interviews conducted with residents revealed that staff meet their dietary needs. (5) out of (12) interviewed residents are on a special diet. (12) out of (12) interviewed residents indicated they do not have any concerns regarding their diets. During the review of the facility records, LPA observed that the facility keeps a list of the dietary needs and restrictions of the residents as ordered by their physicians. LPA toured the kitchen and the dining area and observed the food served to residents were on the menu. LPA also observed that the residents dietary needs list is posted on the board. Therefore, there was insufficient evidence to corroborate with this allegation.

In regards to the allegation: “Staff do not provide adequate amount of food to residents.”, it is alleged that too small quantities of food are provided to the residents without second servings being offered. No other details provided. Staff interviews revealed that staff provide adequate food service to residents. Staff indicated they follow a menu reviewed and approved by a dietitian. Staff also stated that they provide alternative food menu for residents. Interviewed staff stated that they always provide huge amount of servings to the residents. Per staff interviewed, they have not heard or received complaints regarding the amount of food being served to the residents. Interviewed residents indicated the staff provide adequate food service including snacks and do not have any concerns. Interviewed residents indicated that the food servings and portions are adequate. During today’s visit LPA along with S3 toured the Kitchen and pantry areas and LPA observed sufficient food supplies. Between 12pm-12:30pm, LPA toured the dining area during lunch and observed the quantity of food served to the residents are adequate. Therefore, there was insufficient evidence to corroborate with this allegation.

Based on statements and interviews conducted with staff, residents, review of facility file records, there was not enough supportive evidence to concur with the reported allegations. 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 this report was provided to Lisa Gomez, General Manager.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC9099 (FAS) - (06/04)
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