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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603710
Report Date: 06/20/2024
Date Signed: 06/20/2024 12:18:56 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
06/12/2024 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240612155319
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:
06/20/2024
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Manager Lisa GomezTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Air conditioner is in disrepair
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted an initial unannounced complaint investigation visit for the allegation listed above. LPA met with Manager Lisa Gomez and the purpose of the visit was discussed.

LPA's visit consisted of the following: a tour of the phyical plant which included the common rooms and memory care unit, LPA inspected room #'s 161, 165, 166, 170, 180, 181, and 186 which are all part of the memory care unit, LPA interviewed staff #1-6 (S1-S6) and residents #2-5 (R2-R5), Resident #1 (R1) is not available for interview. LPA collected maintenance notes fro the month of June 2024, LPA collected documents from R1's file as well as a copy of the staff and resident roster. The investigation revealed the following:

Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
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-20240612155319
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: 06/20/2024
NARRATIVE
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In regards to the allegation "Air conditioner is in disrepair" it was alleged that the AC in room #166 was not working and the HVAC system for the facility has not been working for a month. (6) of (6) Staff interviewed denied the allegation. (4) of (4) Residents interviewed could not corroborate the allegation. Room #166 is in the facilities memory care unit and LPA observed the AC to be working. LPA observed the AC for the rooms in the memory care unit that were toured to be operating. Staff interviewed denied knowledge that any rooms have a broken AC and added that temperatures are set on the thermometer for each room. Staff interviewed stated they will address any issues as soon as they are aware of them. File review shows that for the month of June there was (1) room with AC issues and it was addressed for room #240. There are no documents on file showing that the HVAC system has been out for a month or that the AC in room #166 was in disrepair. Based on interviews conducted, files reviewed, and observations there was not enough supportive evidence to concur with the reported 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 conducted and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Jose Villalobos
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2