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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603710
Report Date: 10/03/2024
Date Signed: 10/03/2024 12:34:43 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
10/01/2024 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241001133551
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: 41DATE:
10/03/2024
UNANNOUNCEDTIME BEGAN:
09:19 AM
MET WITH:Laura Sanchez - Health Services Director
Lisa Gomez - Administrator		TIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff did not adequately supervise resident in care resulting in resident wandering from the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced initial complaint visit to
investigate the above allegation. LPA met with Laura Sanchez, Health Services Director and discussed the
purpose of the visit. Shortly after, LPA met with Lisa Gomez, Administrator who provided assistance.

The investigation consisted of the following: LPA obtained copies of the Resident & Staff Rosters and Resident #1 (R1) files such as: Face sheet, Admission's Agreement, Physician's Report, Preplacement Appraisal, Personal Rights, Resident Assessment and Current medication list. LPA conducted a walk through of the facility's common areas and Memory Care unit which included, inspecting the back gate in the Memory Care Unit. LPA along with S1 checked the back gate to confirm that the alarm is working. LPA interviewed Staff #1 (S1) - Staff #2 (S2), Witness #1 (W1) and Resident #1 (R1). LPA also interviewed Witness #2 (W2) telephonically and attempted to contact Staff #3 (S3 - Staff #4 (S4) but no response received. *****CONTINUED ON LIC 9099-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: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
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 3
Control Number 28-AS-20241001133551
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: 10/03/2024
NARRATIVE
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The investigation revealed the following:

In regards to the allegation: “Staff did not adequately supervise resident in care resulting in resident wandering from the facility.” It is alleged that R1 was wandering into the traffic and put herself in harm’s way. Interviews with S1-S2 corroborated the allegation. S1 stated that the incident happened early evening on 09/30/2024. S1 indicated that R1 was admitted to the facility recently. S1 stated that what she thinks happened was that R1 went out the back gate and the alarm did not go off. S1 showed LPA how the back gate’s alarm work and it involved 4 steps to secure the gate. S1 indicated that someone must have missed a step or two in locking it, hence the alarm failed to go off. LPA observed that the back gate leads to a driveway towards the main road next to the freeway. Interviews with W1-W2 also corroborated the allegation. W1 stated that she drove around to help in locating R1 and was handed over to her by the authorities and W1 took R1 back to the facility. W1 indicated that she did not observe injury on R1. W2 stated that she called the facility and 911 to report that a resident was walking next to the freeway. Interviewed staff stated that they conducted a body check and assessed R1 as soon as she returned to the facility. LPA interviewed R1 who cannot recall the incident.

Based on LPA’s observations and interviews, 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, Administrator along with the Appeals Rights.

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

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20241001133551
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: 10/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
10/10/2024
Section Cited
CCR
87461(a)(1)
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87461 Mental Condition..(a) The facility shall determine the amount of supervision necessary by assessing the mental status of the prospective resident to determine if the individual: (1) tends to wander;
This requirement is not met as evidenced by:
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The administrator agreed to conduct an in-service elopement training with all the staff and develop a written instruction on how to secure the exit points correctly and properly. Training logs along with the written plan shall be submitted to LPA/CCL by POC due date.
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Based on interviews, observations, records reviews, the Administrator did not ensure that R1 was supervised properly which resulted to R1 wandering into the traffic which poses a potential risk to 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: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3