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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603710
Report Date: 07/16/2024
Date Signed: 07/16/2024 02:12:56 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
07/10/2024 and conducted by Evaluator Jose Villalobos
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240710093533
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:
07/16/2024
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Manager Lisa Gomez TIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility did not update Needs and Services Plans for residents
Facility did not update physicians reports for residents with a change in condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced complaint investigation visit for the allegation(s) above. LPA met with Facility Manager Lisa Gomez and the purpose of the visit was discussed.

LPA conducted the following on todays visit: Toured the physical plant, Interviewed staff #1-#5 (S1-S5) and Residents #1-#5 (R1-R5). LPA reviewed and collected the needs and services plans and physicians reports for R1-R5. LPA also collected a copy of the staff and resident roster. The investigation revealed the following:

In regards to the allegaiton "Facility did not update Needs and Services Plans for residents" it is alleged that the needs and services plans for residents on file are outdated and do not reflect the residents actual care needs. (5) of (5) Staff interviewed denied the allegation...

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: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
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-20240710093533
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: 07/16/2024
NARRATIVE
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(5) of (5) Residents interviewed could not corroborate the allegation. Residents interviewed stated to have been receiving the proper services to care for their needs. File review shows that the facility has been updating and creating needs and services plans for residents every 6 months or when needed. Interviews with staff all explained that needs and services plans are also updated when there are any change in conditions to residents and it will be detailed on the same form. 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.

In regards to the allegation "Facility did not update physicians reports for residents with a change in condition" it alleged that resident physicians reports are outdated and not updated as needed. (5) of (5) Staff interviewed denied the allegation. (5) of (5) Residents interviewed could not corroborate the allegation. LPA was not provided with specific information as to which residents had changes in condition not updated. Per Title 22 Regulation, Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. Regulations add that the licensee shall obtain an updated medical assessment when required by the Department. Review of the residents files shows that the facility acquired physician reports (medical assessments) for the residents prior to admitting them to the facility. There are no documents on file of the department requiring the facility to update physicians reports. Per Title 22 the facility must also ensure that a resident with dementia shall have an annual medical assessment done at least annually, which shall include a reassessment of the resident’s dementia care needs. File review shows medical assessments done for residents with dementia within that timeline. 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: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2