198603710-3-11-2025-28-AS-RORN-DFKVB4-20250409161654

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603710
Report Date: 03/11/2025
Date Signed: 03/11/2025 04:42:21 PM

Unsubstantiated

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
03/05/2025 and conducted by Evaluator Erik Zaragoza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250305143831

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: 66	DATE:	03/11/2025
		UNANNOUNCED	TIME BEGAN:	01:12 PM
MET WITH:	Laura Sanchez - Health Services Director		TIME COMPLETED:	04:47 PM

ALLEGATION(S):

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Staff prevents the residents from having family councils
Staff do not respond timely to the residents alerts
Staff allow a resident to be soiled while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced initial complaint visit to investigate the allegations listed above. LPA met with Laura Sanchez, Health Services Director, and explained the purpose of the visit.

The investigation consisted of the following: During today's visit LPA conducted a tour of the facility, obtained the resident roster, staff roster, an admissions agreement for the facility, the alarm response report for the date of 3/6/2025, the admissions agreement for the facility, interviewed Staff #1 - 5 (S1 - S5), and also interviewed Residents #1 - 8 (R1 - R8).

The investigation revealed the following: In regards to the allegation that "Staff prevents the residents from having family councils," it is alleged that the staff have been preventing the family council from meeting at the facility to address their concerns to the facility.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250305143831

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: 03/11/2025

NARRATIVE

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During interviews with the residents, none of them corroborated the allegation. LPA interviewed four (4) different residents whose family members and friends participate in the family council, and they all stated that their families have not been prevented from participating in the family council. During interviews with staff, none of them corroborated the allegation. One staff member interviewed stated that they do permit the resident council to hold meetings at the facility, and they recently had one last month. Another staff member interviewed stated that they have never ended the resident council or have prevented family from attending the meetings, and that the staff do address the recommendations and concerns of the family council when they are brought to staff's attention. During review of the admissions agreement for the residents, it details the right of resident families to join the resident council.

In regards to the allegation that "Staff do not respond timely to resident's alerts," it is alleged that staff have not been responding to the residents' call pendant requests for assistance in a timely manner, sometimes taking up to 45 minutes to an hour. During interviews with the residents, seven (7) out of eight (8) did not corroborate the allegation. One of the residents stated that whenever they have used their pendant that they also respond to them in an appropriate time frame. Another resident interviewed stated that staff do respond in a very timely manner whenever they request assistance through their call pendant. During interviews with the staff, none of them corroborated the allegation. One staff member stated that they have been conducting ongoing training amongst staff on how to respond to the resident's pendants in an appropriate time frame. Another staff member explained that if a pendant is not responded to in a timely manner the managers are alerted to ensure that the resident gets the assistance they require as soon as possible During review of the Alarm Response Report for the date of 3/6/2025, over 90% of the call pendant requests were answered within 20 minutes. S2 explained there were some aberrations in the report where residents had left the facility or where the pendant was not reset after the resident received assistance.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250305143831

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: 03/11/2025

NARRATIVE

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In regards to the allegation that "Staff allow a resident to be soiled while in care," it is alleged that staff have left a resident in a soiled diaper which led to the resident developing a rash. During interviews with the residents, none of them corroborated the allegation. One resident stated that they do receive all of the assistance and services they require. Another resident interviewed stated that they believe that all of their needs are being met by the facility staff. During interviews with the staff, four (4) out of five (5) interviewed did not corroborate the allegation. One staff interviewed stated that they never intentionally leave residents soiled in their incontinence supplies while in care, and that there are constant training amongst staff with regard to their incontinence care. Another staff interviewed stated that they have not heard of any issues with residents developing a rash due to not being changed, but they added that if this were to ever occur they would immediately notify the resident's doctor for guidance on next steps to treat the rash.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, 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 held, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/11/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC9099 (FAS) - (06/04)

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