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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603710
Report Date: 02/04/2025
Date Signed: 02/04/2025 03:46:08 PM

Substantiated


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
01/30/2025 and conducted by Evaluator Nune Margaryan
COMPLAINT CONTROL NUMBER: 28-AS-20250130173505
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: 69DATE:
02/04/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Laura SanchezTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff did not ensure that sharp objects are inaccessible to residents in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Laura Sanchez HSD (Health Services Director) who assisted with the visit. LPA explained the purpose of today’s visit.

During today's visit, LPA obtained a copy of the staff and resident rosters, reviewed 7 residents files,
interviewed Health Services Director (HSD), Facility Manager, Human Resources Director (HRD), Staff #1 - Staff #2 (S#1 - S#2), and Resident#1 - Resident#7 (R#1 - R#7). LPA also toured the facility including Memory Care Unit with the assistance of the HSD.

Continue 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
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 5
Control Number 28-AS-20250130173505
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: 02/04/2025
NARRATIVE
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Regarding Allegation: Staff did not ensure that sharp objects are inaccessible to residents in care. It was alleged that memory care kitchen has sharp items in drawers that residents can reach.
Interviewed Health Services Director, Facility Manager, Human Resources Director denied the allegation. Interviewed S1 and S2 stated that they didn't see any sharps in the kitchen / dining area in the Memory care unit that accessible to residents. During today's LPA toured the facility including Memory Care Unit. LPA observed a spray bottle of cleaning supply and Heavy-Duty Construction Caulk Gun in the kitchen cabinet unlocked and accessible to the residents. Based on observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated.

Deficiency is being cited today. A copy of this report, 9099-D and appeals rights were provided.


SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20250130173505
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/05/2025
Section Cited
CCR
87309(a)
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The licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
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Licensee/ HSD remove a cleaning supply and Heavy Duty Construction Caulk Gun during the visit. Additionally, licensee / administrator will conduct an in-service training about this section code with all staff and submit an attendance sheet with staff signatures to CCLD by POC due date.
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At the time of visit LPA toured the facility, MCU and observed a spray bottle of cleaning supply and Heavy Duty Construction Caulk Gun in the kitchen cabinet unlocked and accessible to the residents, which poses an immediate health, safety or personal rights risk to persons 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.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
01/30/2025 and conducted by Evaluator Nune Margaryan
COMPLAINT CONTROL NUMBER: 28-AS-20250130173505

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: 69DATE:
02/04/2025
UNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Laura SanchezTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff are not responding to residents call button in a timely manner.
Staff did not ensure that residents physician reports are being updated.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Laura Sanchez HSD (Health Services Director) who assisted with the visit. LPA explained the purpose of today’s visit.

During today's visit, LPA obtained a copy of the staff and resident rosters, reviewed 7 residents files,
interviewed Health Services Director (HSD), Facility Manager, Human Resources Director (HRD), Staff #1 - Staff #2 (S#1 - S#2), and Resident#1 - Resident#7 (R#1 - R#7). LPA also toured the facility including Memory Care Unit with the assistance of the HSD.

Continue 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20250130173505
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: 02/04/2025
NARRATIVE
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Regarding Allegation: Staff are not responding to residents call button in a timely manner. It was alleged that the pendant response times are almost 45 min when residents call.
Interviewed staff denied the allegation. They stated that all the calls go to caregivers pagers and they response time about 10 - 15 minutes and do not exceed more than 15 minutes. Interviewed Health Services Director, Facility Manager, Human Resources Director stated that there is a monitor in the front desk and receptionist can see calls in the monitor. On the monitor shows time of call and the time when it's cleared. Interviewed residents stated that they did not have issues with the response times and stated that staff arrive in a timely manner. They stated someone always response. At the time of tour LPA tested randomly chosen resident's pendant and noticed that staff responded to the calls very quickly.


Regarding Allegation: Staff did not ensure that residents physician reports are being updated. It was alleged that LIC 602 /Physician's Reports are not proper at move in and not updated as needed.
Staff interviewed denied the allegation. Human Resources Director stated that they don't have incomplete files for residents when they move into the community. Health Services Director stated prior to a person's acceptance as a resident, they obtained documentation of a medical assessment, signed by a physician, and keep on file, review of the residents files shows that the facility acquired physician reports (medical assessments) for the residents prior to admitting them to the facility. Also ensure that a resident with dementia shall have an annual medical assessment done at least annually, which shall include a reassessment of the resident’s dementia care needs. File review shows medical assessments done for residents with dementia within that timeline. Interviewed S1 and S2 stated that they didn't notice that residents’ files are incomplete and there are missing documents.

Based on interviews conducted, files reviewed, and observations there was not enough supportive evidence to concur with the reported allegations; 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 conducted and a copy of this report was provided.



















SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5