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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603710
Report Date: 08/20/2024
Date Signed: 08/20/2024 01:22:02 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
08/14/2024 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240814091739
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: 55DATE:
08/20/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Lisa Gomez - General ManagerTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility staff does not provide food of good quality to resident(s) in care.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Bennette Pena and Daniel Konishi conducted an initial complaint visit to investigate the above allegation. LPAs met with Lisa Gomez, General Manager and discussed the purpose of today's visit.

The investigation consisted of the following: LPAs conducted a tour of the facility focusing in the kitchen, and dining areas in the Assisted Living (AL), Skilled Nursing Facility (SNF) and Memory Care Unit (MC), reviewed facility's food supply and menu for the day. LPAs obtained copies of the Resident & Staff Rosters, Weekly and Always available menus and Work estimate pricing from Pro Refrigeration, Inc (dated 8/01/2024 & 8/09/2024). LPAs also interviewed Staff #1 (S1) - Staff #6 (S6) and Resident #1 (R1) - Resident #8 (R8).

*****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: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
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 5
Control Number 28-AS-20240814091739
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: 08/20/2024
NARRATIVE
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The investigation revealed the following:

In regards to the allegation: "Facility staff does not provide food of good quality to resident(s) in care." It is alleged that the facility serves resident cold food, but no further details given. (6) out of (6) staff interviewed denied the allegation. Some staff interviewed stated that they serve good quality of food and food is always served hot/warm. Interviewed staff stated that the facility has food warmers in the kitchen/serving areas in the Assisted Living (AL), Skilled Nursing (SNF) and Memory Care (MC) units to keep the food hot before serving. S1 stated that the facility has an electric food cart to keep the food hot/warm while transporting to different units in the facility. (8) out of (8) residents were unable to corroborate the allegation. Interviewed residents stated that food is always served warm to medium warm, not cold. Additionally, residents stated that they are satisfied with the quality of food and servings. During the facility tour, LPAs observed the food warmers were all set up in the kitchen/serving areas and the facility has sufficient supply of food. LPAs also observed today's lunch and observed good quality of food served. Therefore, there was insufficient evidence to corroborate with this allegation.

Based on observations, statements and interviews conducted with residents and staff, 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 held, and a copy of this report was provided to Lisa Gomez, House Manager.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
08/14/2024 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240814091739

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: 55DATE:
08/20/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Lisa Gomez - General ManagerTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Facility refrigerator is in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Bennette Pena and Daniel Konishi conducted an initial complaint visit to investigate the above allegation. LPAs met with Lisa Gomez, General Manager and discussed the purpose of today's visit.
The investigation consisted of the following: LPAs conducted a tour of the facility focusing in the kitchen, and dining areas in the Assisted Living (AL), Skilled Nursing Facility (SNF) and Memory Care Unit (MC), reviewed facility's food supply and menu for the day. LPAs obtained copies of the Resident & Staff Rosters, Weekly and Always available menus and Work estimate pricing from Pro Refrigeration, Inc (dated 8/01/2024 & 8/09/2024). LPAs also interviewed Staff #1 (S1) - Staff #6 (S6) and Resident #1 (R1) - Resident #8 (R8).
******CONTINUED ON LIC9099-C*****
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20240814091739
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: 08/20/2024
NARRATIVE
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The investigation revealed the following:

In regards to the allegation: "Facility refrigerator is in disrepair." It is alleged that it was overheard that the refrigerator is not functional and is being used for storage. No additional specifics provided. (4) out of (6) staff interviewed are aware that the refrigerator in the main kitchen was broken S1 stated that the refrigerator broke in July 2024 and it used to store drinks such as water, juice, soda cans, but no protein or salad stored in there. S1 also stated that a refrigeration company came 2x (8/01/2024 & 8/09/2024) to inspect and provide estimates to repair the refrigerator. According to S1, the estimates were being reviewed by the Management for approval. Interviewed residents are not aware that the refrigerator was broken. During the tour, LPAs observed that the refrigerator has a sign "Broken, Out of service" on the door. LPAs observed that although the refrigerator is unplugged, drinks and some paper cup supplies are stored inside and being used as storage.

Based on LPAs' observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of this report was provided to Lisa Gomez, General Manager along with the Appeals Rights

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20240814091739
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/03/2024
Section Cited
CCR
87555(b)(29)
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87555 General Food Service Requirements ....(b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair ......
This requirement is not met as evidenced by:
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The Administrator will submit service report/invoice that the refrigerator has been fixed and in use to CCL/LPA by POC due date.
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Based on LPA's observations, interviews and records review, the refrigerator in the main kitchen has been broken since July 2024, currently not yet scheduled to be fixed and being used as storage which posed a potential risk for residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Bennette Pena
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5