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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603710
Report Date: 10/07/2024
Date Signed: 10/07/2024 04:06:49 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/30/2024 and conducted by Evaluator Nune Margaryan
COMPLAINT CONTROL NUMBER: 28-AS-20240930084614
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: 59DATE:
10/07/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Laura Sanchez - Health Service Director
Lisa Gomez - Administrator
TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff do not ensure that resident(s) are provided with activities while in care.
Licensee is not ensuring that staff provide adequate care to resident(s).
Staff are not addressing resident(s) developing skin breakdown while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced complaint investigation visit regarding the above allegations. LPA Margaryan met with Health Services Director (HSD), Laura Sanchez who assisted with the visit. Shortly after, LPA met with Lisa Gomez, Administrator. Purpose for the visit was explained.

During today's visit, LPA Nune Margaryan obtained a copy of the resident and staff roster, copy of the staff schedule for monts of April and May 2024, R1's Physician's Report. LPA tour the facility and inspected randomly choosen residents rooms. Interviewes condacted with Health Service Director, Administrator,
Staff #1 - Staff #4 (S#1 - S#4) and Resident #1 - Resident #6 .(R#1 - R#6).

Continue 9099C
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2024
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-20240930084614
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BAYSHIRE SAN DIMAS
FACILITY NUMBER: 198603710
VISIT DATE: 10/07/2024
NARRATIVE
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Regarding the allegation: Staff do not ensure that resident(s) are provided with activities while in care. It was alleged that Resident #1 who is bedridden, can't watch TV, because TV is not working in the resident room. LPA tour the facility with HSD. Upon walking into the R1 room LPA observed that TV is on and R1 is watching TV. TV is working properly. Interviewed Administrator, HSD stated that they ensure that all residents have the opportunity to participate in activities. Residents care needs are individualized depending on their mobility and what they enjoy. Some residents like to watch TV, listen to music while others prefer visits from team members / staff. Interviewed S3 and S4 stated that if resident can't participate in a group activity, they have alternative activities for them. They do in room visits. They will bring sensory objects, read for residents or music therapy with the residents. 5 out of the 6 residents stated the staff would do activities with them. R1 stated that they liked to watch TV and TV was working in their room.

Regarding the allegation: Licensee is not ensuring that staff provide adequate care to resident(s). It was alleged that facility did not have sufficient staff to provide care to resident, resident needs were not met. Staff didn’t change the resident diaper of extended period of time. R1 lays in their room without having diaper changed. Interviewed HSD, Administrator and staff denied the allegation. They stated that facility has enough staff to provide adequate care to residents in care. They assist residents with all their needs including diaper change all day and night. Facility has a 3-shift scheduled for morning, day, and night. They stated if there is a call off, they will replace the shift. It will be facility staff to work an extra shift or have an med. tech. or RCC (Resident care coordinator) fill in for that shift. Also, they have a contract with outside agencies if needed. Staff indicated that residents' diapers are changed every 2 hours, or as needed to keep them clean and dry. They also stated that each resident has pendant, and they can call/page staff if they need assistance and to have their diaper changed as well. LPA interviewed 6 residents of which 5 are incontinence. The residents interviewed stated the staff check their diapers often and change them as needed. R1 stated that staff do not leave them in soiled diapers. R1 shows their pendant and stated will call if need assistance. While LPA walked around to conduct resident interviews, LPA observed enough staff assisting residents.

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NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240930084614
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BAYSHIRE SAN DIMAS
FACILITY NUMBER: 198603710
VISIT DATE: 10/07/2024
NARRATIVE
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Regarding the allegation: Staff are not addressing resident(s) developing skin breakdown while in care. It was alleged that a lot of residents have bad skin breakdown.
Interviewed HSD, Administrator and staff denied the allegation. They stated that protocol is to report any skin breakdown changes to the Med Tech and HSD (Health Service Director) who then discuss appropriate interventions with staff including Hospice care or Home health. Staff interviewed stated that they do rounds regularly to check on residents. Staff indicated that residents' diapers are changed every 2 hours, or as needed to keep them clean and dry. Staff also stated that they reposition resident to prevent rashes, skin breakdown. Staff also stated that when caregivers notice rashes or skin breakdown while assisting residents, they report it immediately to the Med Tech for assessment. Interviews conducted with residents were consistent with their response that the facility is providing adequate care to meet the needs of the residents.

Based on the observations and interviews conducted with staff and residents, 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 HSD Laura Sanchez.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Nune Margaryan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2024
LIC9099 (FAS) - (06/04)
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