198603710-10-21-2024-28-AS-FFIS-DAY3RP-20241112172904

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603710
Report Date: 10/21/2024
Date Signed: 10/21/2024 05:03:23 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
10/11/2024 and conducted by Evaluator Tyler Reyes

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20241011123713

FACILITY NAME:	BAYSHIRE SAN DIMAS		FACILITY NUMBER:	198603710
ADMINISTRATOR:	COLEMAN, CHAD		FACILITY TYPE:	741
ADDRESS:	1740 S SAN DIMAS		TELEPHONE:	(909) 394-0304
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	119	CENSUS: 71	DATE:	10/21/2024
		UNANNOUNCED	TIME BEGAN:	09:24 AM
MET WITH:	Administrator Lisa Gomez		TIME COMPLETED:	05:20 PM

ALLEGATION(S):

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Staff member works at the facility while under the influence.
Facility is dirty.
Facility is in disrepair.
Staff members CPR Certificate are expired.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tyler Reyes conducted a subsequent complaint investigation visit for the allegations(s) above. LPA Reyes met with Administrator Lisa Gomez and the purpose of the visit was discussed.

Initial visit conducted on 10/18/24 consisted of the following: LPA Vaid toured the physical plant. LPA requested copies of the resident/staff roster. LPA Vaid interviewed (2) staff and (2) residents, LPA Vaid collected the following in-service trainings for the month of August and September.

The investigation consisted of: On 10/21/24, LPA Reyes conducted interviews with Staff #1 (S1- S6), and Residents #1 (R1- R6). LPA Reyes collected copies of Staff and Resident Rosters, Employee Handbook 2024, and October Staff Schedule 2024.

**Continued-LIC9099-C**

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Tyler Reyes
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024

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-20241011123713

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BAYSHIRE SAN DIMAS	FACILITY NUMBER: 198603710
	VISIT DATE: 10/21/2024

NARRATIVE

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The investigation revealed the following:
In regard to allegation “Staff member works at the facility while under the influence” it was alleged that a staff member is arriving to work under the influence of alcohol. (6) of (6) denied the allegation. Staff member indicated that they do not come to the facility drunk and does not drink while at work. Staff indicated the following that they have not heard or witnessed an employee arriving to work intoxicated or drinking while working. Staff indicated they would follow reporting requirements if observed or suspected an employee working while intoxicated or drinking while working. (6) of (6) residents could not corroborate the allegation. Residents indicated they have not heard or witnessed a staff member working while intoxicated.

In regard to allegation “Facility is dirty” it was alleged that kitchen and kitchen silverware is dirty. (6) of (6) denied the allegation. Staff indicated that they have not observed a dirty kitchen or residents eating with dirty silverware. Staff indicated a recent purchase of silverware was made on 10/17/24 for the reason of replacing current silverware with a matching set. Another reason for the purchasing of new silverware was to replace the current silverware that has water spots. (6) of (6) residents denied the allegation. Residents indicated they have not observed using dirty silverware. Resident indicated when at times observing water spots on the silverware but always clean. LPA Reyes observed with S3 the dish washer clean and operational. LPA Reyes observed S3 perform precision chlorine test paper and on the dish washer. Test paper indicated that dish washer is operating within operational requirements

In regard to allegation “Facility is in disrepair” it is alleged that the facility’s doors are not being locked at night. (6) of (6) staff denied the allegation. Staff indicated that when they arrive in the early morning that doors are locked. Staff indicated the only way to gain entrance is through the main entrance of the skilled nursing facility or by contacting the telephone number listed at the facility’s main entrance. (6) of (6) residents could not corroborate the allegation. Residents have indicated no knowledge of the doors of the facility remaining unlock at night.

In regard to allegation “Staff members do not have the required training” it is alleged staff CPR certificates are not current. (6) of (6) denied the allegation. S2 provided LPA Reyes with copies of the October 2024 staff schedule and a list of staff with current CPR certification. Per Title 22, Health and Safety code 1569.618 (3) for Residential Care facilities for the Elderly (RCFE) at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. (6) of (6) residents could not corroborate the allegation. However,neither resident had knowledge if the staffs on duty if CPR was current.

**Continued-LIC9099-C**

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Tyler Reyes
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20241011123713

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: BAYSHIRE SAN DIMAS	FACILITY NUMBER: 198603710
	VISIT DATE: 10/21/2024

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	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. Exit interview held. A copy of the report was provided.

NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Tyler Reyes
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/21/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024

LIC9099 (FAS) - (06/04)

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