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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603710
Report Date: 05/13/2025
Date Signed: 07/08/2025 10:46:42 AM

Unsubstantiated


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
09/12/2024 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240912093951
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: 74DATE:
05/13/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Health Services Coordinator Laura SanchezTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff do not answer resident's calls for assistance timely
Staff do not dispose of soiled diapers properly
Licensee does not ensure sufficient training is provided to staff in the facility
Staff does not ensure emergency evacuation drills are conducted at the facility for residents in care
Staff does not ensure facility is kept free of dust on surfaces
Staff does not ensure window screens are in good repair
Staff do not ensure reporting requirements are being followed
Staff does not ensure chemicals are made inaccessible to residents
Staff does not ensure sharp objects are made inaccessible to residents
Staff do not ensure proper hand hygiene is performed while providing care for residents

INVESTIGATION FINDINGS:
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The purpose of this amended report dated 07/08/2025 is to correct the report (9099 C) dated 05/13/2025 in which LPA inadvertently listed that there were sharp objects when there were no sharp objects.
Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced complaint visit to investigate the above-mentioned allegations and deliver findings.
LPA met with Health Services Coordinator Laura Sanchez and explained the reason for the visit.
At today's visit Resident's R4-R7 were interviewed.
The initial visit was conducted on 09/17/2024 and included the following:
LPA Trueman requested copies of the staff and resident rosters, and interviewed the Manager, Staff 1 - Staff 2 (S1 - S2) and Resident 1 - Resident 3 (R1 - R3)
LPA also toured common areas in memory care and assisted living. In memory care Rooms 161, 180, 186 and 192 were inspected.
In Assisted Living, Rooms 233, 236, 238, 364 and 368 were inspected.
Documentation regarding monthly A/C and heating dated 04/03/24- 09/03/24 was submitted.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
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 4
Control Number 28-AS-20240912093951
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: 05/13/2025
NARRATIVE
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Documentation from J & N Duct Cleaning dated 09/10/2024 was submitted.
In regards to the allegation Staff do not answer resident's calls for assistance timely, based on interviews conducted, information gathered and tour of the facility it was revealed during inspection of rooms 161, 180, 186 ,192 , 233, 236, 238, 364 and 368 pull cord was initiated by LPA and staff responded within 5 to 10 minutes.
Staff stated pendant is monitored at reception and staff will respond quickly. Stated that certain times of day are more busy than others and they have new pagers and have a plan to respond quickly.
5 of 7 residents interviewed stated that they used the pull cord for assistance and staff came quickly to assist. The other 2 residents stated they have not needed any assistance and are independent.
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.
In regards to the allegation Staff do not dispose of soiled diapers properly based on interviews conducted, information gathered and facility tour it was revealed that all rooms inspected there were no bad smell or odors and no soiled diapers in the bathroom.
Staff stated that there has been no complaints and they are really good about that.
3 of 7 residents stated they have had assistance with diaper changes and it has gone well and there has not been any soiled diapers left in the room. 4 residents changed their own diaper.
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.
In regards to the allegation Licensee does not ensure sufficient training is provided to staff in the facility, based on interviews conducted and information gathered staff stated that they have an in-service every month
and additional training's.
Facility submitted staff training documentation covering 08/2024-10/2024. Training contained employee signatures of those who had attended. Topics covered were schedule guideline reminders 08/25/24, Med Tech refresher 09/04/2024, Pendant Response/Call Log 09/09/2024, Safety and Proper Body Mechanics 09/25/2024, Proper Transfer Mechanics 10/08/2024, and Elopements 10/09/2024.
7 of 7 residents stated they feel staff have been trained and that they are efficient and professional.
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.
In regards to the allegation Staff does not ensure emergency evacuation drills are conducted at the facility for residents in care, staff stated that drills are done every month and also additional training's.
5 of 7 residents stated that evacuation drills have been conducted. 2 residents were unsure.
Facility submitted Fire Drill Report conducted by Southwest Fire and Safety which included order of evacuation drill. Log of those who had attended was submitted for the following dates:08/25/2024, 09/14/2024 and 04/16/2025.
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.
In regards to the allegation Staff does not ensure facility is kept free of dust on surfaces, based on interviews conducted and information gathered it was revealed on tour of the facility and resident rooms by the LPA that



NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20240912093951
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: 05/13/2025
NARRATIVE
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rooms were clean and there was no dust observed on the surfaces.
Staff stated that housekeeping is here every day and in every unit.
7 of 7 residents stated that staff does a great job keeping the facility and rooms clean and they have not observed any dust on surfaces.
Documentation of monthly A/C and heating dated 04/03/24- 09/03/24 was submitted in which a/c and heating are checked monthly and filter changed monthly.
Documentation from J & N Duct Cleaning dated 09/10/2024 was submitted in which the air ducts are taken care of in the building.
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.
In regards to the allegation Staff does not ensure window screens are in good repair, based on interviews conducted, information gathered and tour of resident rooms it was revealed during inspection of resident rooms 161, 180, 186, 192, 233, 236, 238, 364 and 368 that all screens were in good repair.
Resident's R1-R7 all stated that the screens in their rooms are all in good condition.
Staff stated that all screens are in good repair and that maintenance is on site to fix things right away.
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.
In regards to the allegation Staff do not ensure reporting requirements are being followed, based on interviews conducted and information gathered staff stated that Special Incident Reports (SIR's) are always completed and submitted to licensing promptly.
Facility submitted Special Incident Reports (SIR's) covering September 2024- November 2024 to LPA.
LPA verified the reports which included 2 residents SIR reports 09/12/2024, SIR 09/14/2024, SIR 09/15/2024, Notification of Hospice Services 2 resident's 09/28/2024, and 09/30/2024 Death Report 09/30/2024.
In October Death Report 10/06/2024, SIR 10/17/2024, Death Report 10/21/2024, SIR 10/23/2024, Notification of Hospice Services 10/24/2024, 2 SIR's 10/26 and Death Report 10/31/2024.
In November Notification of Hospice Services 11/01/2024, SIR 11/02/2024, Death Report 11/03/2024, SIR 11/03/2024, Death Report 11/04/2024, SIR 11/07/2024, SIR 11/13/2024, Notification of Hospice Services 11/13/2024 and SIR 11/23/2024 and 2 Death Reports 11/23/2024.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did no t occur, therefore the allegation is UNSUBSTANTIATED.
In regards to the allegation Staff does not ensure chemicals are made inaccessible to residents, based on interviews conducted, information gathered and tour of resident rooms it was revealed during inspection of resident rooms 161, 180, 186, 192, 233, 236, 238, 364 and 368 that there were no chemicals accessible to residents in their rooms.
Resident's 1-7 all stated there are no chemicals in their rooms and nothing poisonous.
Staff stated that all chemicals are locked up.
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.





NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 28-AS-20240912093951
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: 05/13/2025
NARRATIVE
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In regards to the allegation Staff does not ensure sharp objects are made inaccessible to residents, based on interviews conducted, information gathered and tour of resident rooms it was revealed during inspection of resident rooms 161, 180, 186, 192, 233, 236, 238, 364 and 368 that there were no sharp objects accessible to residents in their rooms.
Resident's 1-7 all stated that there are no sharp objects in their rooms.
Staff stated that any sharp objects are kept in an appropriate place away from residents.
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.
In regards to the allegation Staff do not ensure proper hand hygiene is performed while providing care for residents 7 of 7 residents stated that staff do have proper hand hygiene and wear gloves when serving food
and administering medication.
Staff stated that they use universal precautions and wash their hands after resident care.
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.

Exit interview conducted.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4