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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 04:11:04 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 Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240814123547
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:
08/20/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Resident Services Director- Laura Sanchez TIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff are mishandling the residents medications
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 08/20/2024 regarding the above allegation. LPA Ramirez was greeted by Human Resources Manager- Nadia Batista and explained the purpose of the visit. Resident Services Director- Laura Sanchez arrived shortly after to assist with tour.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff Roster, Staff#1 - 5 interviews (S1 – S5), Resident Interviews #1-5 (R1 – R5), Medications Destruction Log (LIC 622), Facility Narcotics Shift Log for July 1, 2024, through August 19,2024, and physical plant tour.

SEE 809-C for continuation.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
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 2
Control Number 28-AS-20240814123547
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. Regarding Allegation: Staff are mishandling the residents’ medications- It is alleged staff did not document the destruction of medications, ensure medications and narcotics were centrally stored and inaccessible to persons other than employees responsible their supervision, and missing medications. Five (5) out of the five (5) staff interviewed deny this allegation. Five (5) out of the five (5) residents interviewed deny this allegation. Interviews with staff revealed on or around 8/14/2024, several resident medications which were scheduled to be destroyed, were observed to be secured in the facility medications cart but, still needed to be logged for destruction. Facility management became aware on 8/14/24 and medications were logged for destruction and destroyed. Interviews with residents revealed staff provides residents with medications as needed and residents receive their medications as ordered. Per Title 22, Incidental Medical and Dental Care-87454(i)(1)(2)(3)(4)- Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following: (1) Name of the resident. (2) The prescription number and the name of the pharmacy. (3) The drug name, strength and quantity destroyed. (4) The date of destruction. LPA Ramirez reviewed medications destruction log for twenty (20) residents and observed the logs to list the name of the resident, prescription number and name of the pharmacy, name of drug, strength and quantity destroyed, and date of destruction. LPA Ramirez reviewed and obtained copies of July 2024 and August 2024 Narcotic Shift Count log for the facility memory care unit and assisted living. LPA Ramirez did not observe any documented discrepancies on these logs. During tour of facility, LPA Ramirez observed memory care medications room to be inaccessible to residents in care and observed one (1) staff to have sole custody of the key required to open the medications room door. LPA Ramirez observed the assisted living medications cart to be inaccessible to residents in care and observed one (1) staff to have sole custody of the key required to access medications cart. LPA Ramirez toured the facility health center room located on the 3rd floor. Room was observed to be inaccessible to residents in care. LPA Ramirez did observe resident charts in this room and did not observe medications in this room. 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.

No deficiencies were cited today. Exit interview was conducted. A copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
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 2