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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603710
Report Date: 07/18/2024
Date Signed: 07/18/2024 04:14:25 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
05/23/2024 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240523135252
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:
07/18/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Lisa Gomez, ManagerTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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1. Hazardous chemicals are left accessible to residents.
2. Staff not monitoring resident with sharp objects.
3. Staff left resident unattended.
4. Staff interfere with family council meetings.
5. Staff did not follow up on family council meeting concerns in a timely manner.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint visit for the above allegations. LPA met with Lisa Gomez and explained the reason for the visit.

The investigation consisted of the following:
On 5/28/24, LPA Chan conducted the initial visit to gather documents and interviewed the facility manager, 5 staff and 5 residents. During the visit today, LPA interview a staff and reviewed personnel files.

The investigation revealed the following:
For allegations – “Hazardous chemicals are left accessible to residents” and “Staff not monitoring residents with sharp objects”. LPA toured the assisted living and memory care unit and interviewed staff and residents. LPA did not see any chemicals or sharp objects left accessible to residents. The cleaning solutions were locked in the cleaning carts or the storage room. Per staff, scissors are put away after usage.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024
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-20240523135252
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: 07/18/2024
NARRATIVE
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Residents interviewed stated they had not seen any lying around. In the memory care unit, anything that needs to be cut is usually prepared beforehand. Therefore, staff do not normally give residents scissors to cut and if they do, they will monitor the resident(s).

Allegation - Staff left resident unattended. It is alleged that the staff left a resident with dementia alone in the assisted living side because the resident did not want to finish the walk. LPA toured the memory care unit which requires a code to exit. Per staff, residents are taken to the front of the facility for walks and to do community activities. They are always supervised by the wellness director and/or care staff. All the staff interviewed denied ever leaving a resident unsupervised in the assisted living area. They are aware that the residents residing in the memory care unit must be monitored at all times. Residents interviewed have not seen any residents being left unsupervised when they come out for walks or activities.

For allegations - “Staff interfere with family council meetings” and “Staff did not follow up on family council meeting concerns in a timely manner”. It is alleged that the facility does not send out mailings or families are not made aware of the monthly meetings. The facility manager stated that they have a separate resident and family council meeting each month. The council meetings are posted by the sign-in sheet in the front lobby to inform them of upcoming meeting. She stated that the meetings are coordinated by the activity director. It was also noted that family members did not want residents to attend their council meetings as there is a separate resident council and would invite staff if they wanted them at the meeting. LPA interviewed residents who also stated they do not usually go to the family council meetings as those are mainly for families. As for following up on family concerns, the facility manager and staff who attended the meetings indicated they listened to their concerns and address them right away.

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.



An exit interview was conducted with Manager Lisa Gomez. A copy of this report along with the appeal rights was provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2