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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603710
Report Date: 03/12/2025
Date Signed: 03/12/2025 01:18:48 PM

Document Has Been Signed on 03/12/2025 01:18 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 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: 73DATE:
03/12/2025
TYPE OF VISIT:OfficeUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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An Informal Conference meeting was held at Monterey Park Adult and Senior Care Regional Office. Present during this meeting were License Program Manager (LPM) Fernando Fierros and License Program Analysts (LPAs) Blanca Gonzalez, Jose Villalobos, and Luis De Leon. The following representatives were present from Bayshire San Dimas: Operation Manager Tanner Peterson, Director of Operations Chad Coleman, and Health Services Director Laura Sanchez.

The Informal Conference was conducted to discuss the oversight of the facility, specifically to address the number of complaints received since the facility was licensed and Title 22 violations, administrator hours and hospice waiver increase requests.

The following topics were discussed:
· Hospice Waiver Increase request from 30 to 38. Health Director Laura Sanchez provided a copy of the Hospice letter Increase from twenty (20) to thirty (30) hospice residents.
· Title 22 regulations regarding administrator qualifications and administrator to be on site sufficient number of hours to permit adequate attention to the management and administration of the facility.
· LIC-308 Designation of Facility Responsibility - Administrator to declare a responsible staff for each shift that meets qualification in the absence of the Administrator.
· LIC 500 - Staff Schedule to contain administrator hours and be available to the department as needed.
· High Volume of complaints for the facility and that the Administrator is to provide oversight regarding staff training and resident concerns.
· Licensee Annual Fees
· Bedridden Plan

See Continuation Page LIC 809C.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Luis DeLeon
LICENSING EVALUATOR SIGNATURE: DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/12/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/12/2025
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The following documents were requested:
  • Updated Hospice Waiver Increase Request that includes statements that comply with Title 22 regulations for Section 87632 Hospice Care Waiver.
  • Hospice Waiver Increase request letter signed by the licensee.
  • LIC 500 Personnel Record which indicates the current staff schedule and includes the administrator schedule.

During meeting Administrator agrees to the following:
Provide an updated staff schedule upon the department’s request.
Submit an updated LIC-308 Designation of Facility Responsibility to department that covers each shift.

Operation Manager and Director explained internal procedures to mitigate the number of complaints.

LPM Fierros discussed the number of citations issued to the facility from the date the license was issued to the current date and provided the Administrator with copies of Title 22 regulations for which facility had been cited. A copy of POC's were provide to Administrator. The following regulations were reviewed.

87468.1 Personal Rights of Residents in All Facilities
87405 Administrator - Qualifications and Duties
87355 Criminal Record Clearance
85707 Admission Agreement
87411 Personal Requirements
87303 Maintenance & Operation
87705 Care of Persons with Dementia
87309 Storage Space

Exit interview was conducted and a copy of the report was provided to Administrator Chad Coleman.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Luis DeLeon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC809 (FAS) - (06/04)
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