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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603710
Report Date: 11/13/2024
Date Signed: 11/13/2024 11:47:40 AM

Document Has Been Signed on 11/13/2024 11:47 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 DIMASFACILITY NUMBER:
198603710
ADMINISTRATOR/
DIRECTOR:		COLEMAN, CHADFACILITY TYPE:
741
ADDRESS:1740 S SAN DIMASTELEPHONE:
(909) 394-0304
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY: 119CENSUS: 65DATE:
11/13/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Lisa Gomez - Administrator TIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced case management visit during a complaint investigation visit. LPA met with Lisa Gomez and explained the reason for the visit.

On 11/13/24 LPA Flores conducted a health and safety check tour at the facility and observed the following:
  • A pair of large scissors and a knife in the dementia kitchenette in an accessible drawer
  • A cabinet door was in disrepair.
  • Water temperature was tested in each residents room and tested between 71.5-109.4 degrees F., which is not within the required 105-120 degrees F. Room #192 tested at 109.4 degrees F., room #167 tested at 102.8 degrees F., room #234 tested at 86.8 degrees F., room #224 tested at 71.5 degrees F., room #153 tested at 105.2 degrees F., and room #151 tested at 108.5 degrees F.


Deficiencies were noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/13/2024 11:47 AM - It Cannot Be Edited


Created By: Mary G Flores On 11/13/2024 at 11:25 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 11/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/14/2024
Section Cited
CCR
87705(f)(1)

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87705 Care of Persons with Dementia:(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidence by:
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Administrator will ensure maintenance provides a lock in drawer were knife and scissors are stored and will submit a picture to the department by POC due date 11/14/24.
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Based on observation licensee did not ensure knife and scissors were stored inaccessible to the residents in the dementia kitchennete which poses an immediate risk to the health, safety, or personal rights of the persons in care.
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Type B
11/20/2024
Section Cited
CCR87303(a)(1)

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87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidence by:
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Administrator put a repair request order with maintenance to repair the cabinet and water temperature during this visit. Administrator will submit a picture of cabinet repair, and a water temperature log for 7 days by POC due date 11/20/24.
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Based on observations licensee did not ensure dementia's unit kitchennete cabinet was in good repair, and that water temperature was within the required 105-120 degrees F., water temperature tested as follow in room #167- 102.8, room #234- 86.8, room #224 - 71.5 degrees F. (Cont)
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which poses a potential risk to the health, safety, or personal rights of the persons in care.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2024


LIC809 (FAS) - (06/04)
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