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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603710
Report Date: 03/14/2025
Date Signed: 03/14/2025 04:14:21 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
11/26/2024 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241126105756
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: 65DATE:
03/14/2025
UNANNOUNCEDTIME BEGAN:
08:18 AM
MET WITH:Human Resources Manager, Nadia Batista,TIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Staff neglect resulted in a resident's death.
Staff had unauthorized access to a resident's personal funds.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 03/14/2025 regarding the above allegations. LPA Ramirez conducted subsequent complaint visit on 12/06/2024 and a needs further investigation was documented. LPA Trueman conducted Health & Safety check on 11/26/2024 and a needs further investigation was documented. During today’s visit, LPA Ramirez was greeted by Human Resources Manager, Nadia Batista, and explained the purpose of the visit.
The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster (LIC 9020), Staff#1 - 4 interviews (S1 – S4), Attempted interview of resident#1 (R1), Resident#2-5 interviews (R2-R5), Interview with R1’s family, copies of Resident#1 (R1)- face sheet, emergency contact information, hospice care orders, hospice medications list, hospice progress notes, medical assessment, medication administration record (MAR) for the month of November 2024, death certificate for R1, facility staff care notes for R1 for the month of November 2024, and death report (LIC 624A) and physical plant tour.
SEE 9099-C for continued report
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025
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-20241126105756
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: 03/14/2025
NARRATIVE
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The investigation revealed the following. Regarding Allegation(s): Staff neglect resulted in a resident's death – It is alleged facility staff neglected R1 which resulted in R1’s death. Review of R1’s resident records revealed R1 was admitted into the facility on 06/21/2023 and was self-responsible. R1 was transferred from another hospice care provider on 11/04/2024 and new hospice care orders were placed. On 11/05/2024, during hospice care visit, hospice care staff documented R1 requested that medication ordered on 11/04/2024, not be ordered and administered unless “absolutely necessary”. On 11/05/2024, R1’s physician ordered R1 discontinue the use of Morphine Sulfate 10mg/0.5 ml- every 4 hours as needed, Lorazepam 1mg/0.5m- every 6 hours as needed, Morphine Sulfate 20mg/1ml- every 4 hours as needed, Morphine Sulfate 5mg/0.25ml- every 4 hours as needed, Lorazepam 1 tab- every 4 hours as needed. Review of R1’s hospice care notes and facility care notes revealed hospice staff and facility staff regularly documented R1’s care and supervision. Review of R1’s death certificate did not corroborate above allegation. Four (4) out of the four (4) staff interviewed denied above allegation. Four (4) out of the four (4) residents interviewed denied above allegation. R1 was not available for interview. Interview with R1’s family did not corroborate this allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Staff had unauthorized access to a resident's personal funds- It is alleged facility staff were monitoring R1’s financial situation. Review of R1’s resident records revealed R1 was admitted into the facility on 06/21/2023 and was self-responsible. Four (4) out of the four (4) staff interviewed denied above allegation. Four (4) out of the four (4) residents interviewed denied above allegation. Interview with R1’s family did not corroborate this allegation. Review of R1’s facility record, including payments made to the facility for services, did not corroborate above allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.


No deficiencies were cited during this complaint investigation visit. Exit interview was conducted. A copy of this report was provided via email.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025
LIC9099 (FAS) - (06/04)
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