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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603710
Report Date: 08/22/2024
Date Signed: 08/22/2024 06:27:26 PM

Substantiated


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: 56DATE:
08/22/2024
UNANNOUNCEDTIME BEGAN:
02:32 PM
MET WITH:Nadia Bautista, HR staffTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff were not fingerprint cleared prior to working with residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint visit on the allegation listed above. LPA met with Staff, Nadia Bautista, and explained the reason for the visit.

On 5/28/24, LPA Chan toured the facility and obtained copies of the staff and resident rosters. Interviews were held with the Manager, 5 Staff, and 5 Residents. LPA requested copies of documents for Staff #2 - #6 to be emailed to LPA: Personnel Record with date of hire and Background clearance letter. On 7/18/24, LPA Chan interviewed another staff and reviewed personnel files.

For allegation, staff were not fingerprint cleared prior to working with residents in care. LPA interviewed staff who denied working before they obtained background clearance. Staff indicated the process before they start is to obtain fingerprint clearance. LPA reviewed the background clearance letters for 6 personnel files. One out of the six staff received the background clearance letter on 5/3/24 but was hired on 4/1/24.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
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-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: 08/22/2024
NARRATIVE
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It is confirmed today that Staff #3 began working on 4/1/24.

Based on record review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D. A civil penalty is also assessed for this deficiency.

An exit interview was conducted. The Plan of Correction was reviewed and developed with the facility manager. A copy of this report and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/23/2024
Section Cited
CCR
87411(g)(1)
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87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees...shall: (1) Obtain a California clearance....as required by law or Department regulations
This requirement is not met as evidenced by:
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Administrator shall review the regulation 87411 and ensure all employees obtain a background clearance prior to working. A statement acknowledging this regulation shall be submitted to LPA by 8/24/24.
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Based on record review, Staff #3 started working prior to obtaining verification of background clearance which poses an immediate health and safety concern to residents in care.
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Note: Staff #3 had received the background clearance letter on 5/3/24.

***A civil penalty has been assessed for this deficiency.****
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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: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Cynthia D Chan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 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
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: 56DATE:
08/22/2024
UNANNOUNCEDTIME BEGAN:
02:32 PM
MET WITH:Nadia Bautista, HR StaffTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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1. Staff records are not properly maintained.
2. Staff are not properly qualified.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint visit on the allegations listed above. LPA met with Staff, Nadia Bautista, and explained the reason for the visit.

On 5/28/24, LPA Chan toured the facility and obtained copies of the staff and resident rosters. Interviews were held with the Manager, 5 Staff, and 5 Residents. LPA requested copies of documents for Staff #2 - #6 to be emailed to LPA: Personnel Record with date of hire and Background clearance letter. On 7/18/24, LPA Chan interviewed another staff and reviewed personnel files.

For allegations – Staff records are not properly maintained, and Staff are not properly qualified. LPA selected 7 staff files to review which included the administrator and facility manager. The records are maintained at the facility in the HR office.
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: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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: 08/22/2024
NARRATIVE
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The personnel files included the personnel record, health screening, TB results, and training hours. The administrator has the required training to receive the administrator’s certificate. LPA interviewed a total of 7 staff, and all stated they received their initial training during orientation and receive continuous training during the year.

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 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: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5