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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603710
Report Date: 12/10/2024
Date Signed: 12/10/2024 12:07:46 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
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:
12/10/2024
UNANNOUNCEDTIME BEGAN:
10:17 AM
MET WITH:Laura Sanchez - Health Services DirectorTIME COMPLETED:
12:05 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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****This report supersedes the original complaint investigation report dated 10/03/2024. The report is being superseded to include additional information not included on the original report dated 10/03/2024 and to correct the deficiency that was cited from a Type B to a Type A, as well as to update the regulation that was cited. The investigation finding remains SUBSTANTIATED. *****

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent complaint visit to add additional information not included on the report dated 10/03/2024 and update the deficiency cited. LPA met with Laura Sanchez, Health Services Director and explained the reason for the visit.
The investigation consisted of the following: On 10/03/2024, LPA obtained copies of the Resident & Staff Rosters and Resident #1 (R1) pertinent files. LPA conducted a walkthrough of the facility's common areas and Memory Care unit which included, inspecting the back gate in the Memory Care Unit and took pictures/video of the back gate. 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.
During today's visit, LPA obtained copies of the resident & staff rosters, Memory Care unit staff schedule (10/03/2024) and took additional photos of the back gate and exit doors in the MC unit. ****REPORT CONTINUED ON LIC9099-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: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
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: 12/10/2024
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 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. Interviewed staff stated that they conducted a body check and assessed R1 as soon as she returned to the facility. W2 stated that she called the facility and 911 to report that a resident was walking next to the freeway. LPA interviewed R1 but cannot recall the incident. Based on file reviews, resident assessment record indicated that R1 is a wanderer who requires multiple behavioral interventions for redirection including wandering. The physician’s report dated 08/19/2024 indicates that R1 is diagnosed with dementia. The facility rosters dated 10/03/2024 specified a total of 19 memory care residents including R1, 7 caregivers and 3 med techs assigned on different shifts in the memory care unit. However, when R1 wandered away from the facility on 9/30/2024, there were only (2) caregivers and (1) med tech working. Therefore, there was sufficient evidence to corroborate the allegation of lack of supervision which led to R1 wandered from the facility.

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 Laura Sanchez, Health Services Director along with the Appeals Rights.

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

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
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: 12/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/11/2024
Section Cited
CCR
877705(c)(4)
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87705 Care of Persons with
Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.
This requirement is not met as evidenced by:
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The facility shall ensure that there’s adequate number of direct care staff to support and maintain necessary supervision of residents. The administrator will ensure that appraisals are conducted on dementia residents on an ongoing basis and assessed annually. Administrator agreed to update the elopement policy in their plan of operation
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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 an immediate risk to residents in care.
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and conduct an in-service elopement training with all the staff. Lastly, administrator will 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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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: 12/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3