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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603710
Report Date: 08/27/2024
Date Signed: 08/27/2024 10:43:52 AM

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
07/24/2024 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240724144927
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: 54DATE:
08/27/2024
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Lisa Gomez and Laura Sanchez/S-1TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff do not respond to resident's call for assistance in a timely manner.
Staff do not meet resident's dental hygiene and toileting needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to investigate the above allegation. LPA met with Lisa Gomez and discussed the purpose of today’s visit. Laura Sanchez/S-1 arrived at approximately 9 A.M.. and assisted with this visit.

LPA Irra conducted the initial investigation visit on 08/01/24. During this visit, LPA obtained a copy of the resident and staff rosters, a list of residents that are currently receiving hospice services, pendant call log, interviewed Staff #1 (S-1) through Staff #5 (S-5) and interviewed Resident #1 (R-1), Resident #3 (R-3) and Resident #4. LPA was unable to interview Resident #2 (R-2) as R-2 was asleep during this visit. LPA also interviewed Resident #5 (R-5).

Refer to LIC 9099C for the continuation of this report.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
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-20240724144927
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: 08/27/2024
NARRATIVE
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Staff do not respond to resident's call for assistance in a timely manner. It has been alleged that residents press their call button and it takes (30) minutes for staff to come check on residents. (4) out of (5) resident interviews revealed that staff have taken more than (30) minutes to respond to residents’ pendant calls to assist with their care needs. LPA also obtained and reviewed this facility’s alarm response report (pendant call log for 07/31/24 through 08/01/24 [8:40 A.M..]) and observed approximately (14) pendant alarms which reflect that staff took more than (30) minutes to respond residents’ pendant calls. Resident interviews and alarm response report (pendant log) corroborates this allegation.

Staff do not meet resident's dental hygiene and toileting needs. It has been alleged that staff are not providing oral care to residents who need assistance and toileting is not being done timely. (4) out of (5) resident interviews revealed that residents are not receiving oral care and/or assistance with toileting in a timely manner. Interviewed residents revealed that staff (at times) take (30) minutes to (1) hour to attend to residents’ dental hygiene and/or toileting needs. LPA also obtained and reviewed this facility’s alarm response report (pendant call log for 07/31/24 through 08/01/24 [8:40 A.M..]) and observed approximately (14) pendant alarms which reflect that staff took more than (30) minutes to respond residents’ pendant calls. Resident interviews and alarm response report (pendant log) corroborates this allegation.

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

Exit interview conducted, appeal rights and a copy of this report was provided to Laura Sanchez/S-1

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20240724144927
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: 08/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2024
Section Cited
CCR
87411(a)
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Personnel Requirements-General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance
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Facility Administrator to ensure this facility has personnel at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

Facility Administrator to provide a training for staff and discuss the importance of
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and care as required in Section 87608, Postural Supports. This standard is not met as evidence by: At times, staff are taking more than (30) minutes to respond to residents’ pendant calls and to meet residents’ oral care and/or toileting needs in a timely manner.
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responding to resident needs in a timely manner. Facility Administrator to submit proof of training and statement pertaining to this regulation to LPA Irra by POC due date.
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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: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
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
07/24/2024 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240724144927

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: 54DATE:
08/27/2024
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Lisa Gomez and Laura Sanchez/S-1TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff are pushing residents that do not require hospice to agree to hospice care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted a subsequent visit to investigate the above allegation. LPA met with Lisa Gomez and discussed the purpose of today’s visit. Laura Sanchez/S-1 arrived at approximately 9 A.M.. and assisted with this visit. '

LPA Irra conducted the initial investigation visit on 08/01/24. During this visit, LPA obtained a copy of the resident and staff rosters, a list of residents that are currently receiving hospice services, pendant call log, interviewed Staff #1 (S-1) through Staff #5 (S-5) and interviewed Resident #1 (R-1), Resident #3 (R-3) and Resident #4. LPA was unable to interview Resident #2 (R-2) as R-2 was asleep during this visit. LPA also interviewed Resident #5 (R-5).

Refer to LIC 9099C for the continuation of this report.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
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-20240724144927
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: 08/27/2024
NARRATIVE
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Allegation: Staff are pushing residents that do not require hospice to agree to hospice care. It has been alleged that staff are forcing residents who do not require hospice care to agree to hospice services or they will be evicted. Per staff interviews, staff are not pushing residents that do not require hospice to agree to hospice care. Per staff interviews, residents are not threatened to be evicted if they do not agree to hospice care. Staff interviews revealed that S-1 is the person responsible to work with hospice care agencies. Per S-1, S-1 works with hospice care agencies once the resident’s physician has ordered hospice services. Per S-1, once the residents are referred to hospice services by their physician, S-1 provides the resident with different hospice agency options to select from. Per S-1, there are (7) different hospice agencies that provide hospice care for residents under hospice services at this facility. Resident interviews revealed that staff are not pushing residents into receiving hospice care or are threatened to be evicted if hospice services are not obtained. Interviewed residents indicated that hospice services were ordered by their physicians and not staff from this facility. Interviewed residents also indicated that they were provided with different hospice agency options. Interviewed residents indicated they do not have any concerns pertaining to this matter. Interviews do not corroborate this 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 conducted, appeal rights and a copy of this report was provided to Laura Sanchez/S-1.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5