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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603710
Report Date: 07/30/2024
Date Signed: 07/30/2024 12:43:02 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
07/25/2024 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240725121434
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: 51DATE:
07/30/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Chad Coleman - AdministratorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Facility did not update physicians reports for residents with a change in condition.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced complaint investigation visit for the above-mentioned allegation. LPA met with Nadia Batista, HR Director and explained the purpose of the visit. Shortly after, Administrator Chad Coleman arrived and assisted LPA with the investigation.

The investigation consisted of the following: LPA conducted a tour of the physical plant, interviewed Staff #1 (S1) - Staff #5 (S5) and Resident #1 (R1) – Resident #6 (R6). LPA reviewed and obtained copies of the Resident & Staff Rosters, Random Memory Care and Assisted Living residents - Resident #1 (R1) - Resident #6 (R6) files such as: Identification and Emergency Information (Face sheet), Appraisal/Needs and Services plans and Physicians’ reports.

The investigation revealed the following:
In regards to the allegation: “Facility did not update physicians reports for residents with a change in condition.” It is alleged that the residents’ physicians’ reports are not updated timely and the true needs of residents are not current. No other information provided. All (5) staff interviewed denied the allegation. S2 stated that residents physicians reports are updated regularly and facility follows Title 22 regulations. *****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: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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Control Number 28-AS-20240725121434
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: 07/30/2024
NARRATIVE
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S2 stated that a resident is reassessed when there's a change in condition and at that time, the appraisal/needs services plan and the physician's report are completed/updated. S2 indicated that dementia residents receive an annual medical assessment or as needed. Some staff interviewed stated that they address the needs of the residents based on the daily care assignments given to them and they ensure that residents are cared for with their activities of daily living. (6) out of (6) residents interviewed stated that they are comfortable living in the facility and staff attend to their needs. There was no mention of the specific resident(s) nor information provided as to which physician’s report was not updated timely. Documentation reviewed for (6) random residents in Memory Care and Assisted Living reveals that the facility maintains records of their Physicians’ report signed and dated by a physician, made within the last year. Some files also included up to date reassessment of the residents’ dementia care needs. Reviewed files also show the completed appraisal/needs and services plans identifying the functional capabilities and limitations of the residents.

Based on statements and interviews conducted with residents and staff as well as reviewed files and documentation, there was not enough supportive evidence to corroborate the allegation.



Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview and a copy of this report was provided to Chad Coleman, Administrator.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024
LIC9099 (FAS) - (06/04)
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