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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603710
Report Date: 06/26/2025
Date Signed: 06/26/2025 05:02:06 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
06/20/2025 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250620120801
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: 76DATE:
06/26/2025
UNANNOUNCEDTIME BEGAN:
11:19 AM
MET WITH:Laura Sanchez, Health Services DirectorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not ensure resident's dietary needs were met resulting in the resident choking.
Staff did not provide resident's advance directive and/or request to emergency personnel.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit with Health Services Director Laura Sanchez.

The investigation consisted of: Record review, physical plant inspection of Memory Care Unit, interviews with staff (S1-S5) and residents (R1- R5). Copies of relevant documents pertaining to resident (R1) were obtained, as well as LIC 500 Personnel Report and resident roster.

*See next page for narrative.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025
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-20250620120801
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: 06/26/2025
NARRATIVE
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Allegation: Staff did not ensure resident's dietary needs were met resulting in the resident choking. The complaint alleges that on 6/15/2025 during breakfast meal time Memory Care resident (R1) was served the wrong diet plate and choked on a piece of sausage. According to information obtained, at the time of the incident R1 was on mechanical soft diet, but was given a regular diet plate. A total of five (5) residents were interviewed. None of the residents reported issues with the facility not following their physician order diet. Based on staff interviews, a staff person observed the resident choking and gasping for air. Staff immediately performed Heimlich maneuver and inserted two fingers when the food item was not being expelled. After the piece of sausage was expelled the resident displayed shortness of breath, which resulted in need of emergency services. All staff interviewed confirmed the resident choked because they were served the wrong food diet plate. Staff interviews revealed the staff person who served R1 their plate was unaware the resident required a special diet. Record review confirmed R1 required a mechanical soft diet at the time of the incident. There is sufficient evidence to corroborate the allegaiton.

Allegation: Staff did not provide resident's advance directive and/or request to emergency personnel.
It is alleged that facility staff did not provide emergency personnel resident (R1's) "Do Not Resuscitate [DNR]" form and other necessary records. A total of five (5) residents were interviewed. None reported issues with POLST or DNR documents. Staff interviews revealed that on June 15, 2025, when 911 emergency services personnel arrived at the facility and determined the resident required transport to the hospital, staff were not able to print any of the residents documents that are normally provided to emergency personnel. Staff stated that the med-tech room computer broke the day before, and the computer used the day of the incident had printing issues. Therefore, emergency personnel were not provided necessary documents i.e., Face Sheet, medication list, POLST/DNR, and medical assessment. Staff stated they asked paramedics to take a picture of the records. It is unknown which documents the paramedics took pictures of. Advance directive and/or request regarding resuscitative measures forms shall be presented to the responding emergency medical personnel. Therefore, there is sufficient evidence to corroborate the allegation.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

An exit interview was conducted with Human Resources Director Nadia Batista. A copy of the report and appeal rights were issued.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20250620120801
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: 06/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/27/2025
Section Cited
CCR
87555(b)(7)
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General Food Service Requirements. The following food service requirements shall apply: Modified diets prescribed by a resident's physician as a medical necessity shall be provided.

This requirement was not met evidenced by:
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Administration staff agreed to conduct training.
1. Submit a written plan of correction by tomorrow.
2. Conduct in-service training to all staff on modified diets, choking/aspiration, and dietary restrictions.
3. Submit staff training evidence by 7/1/25.
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Based on interviews/record review, on 6/15/25 Memory Care Unit resident (R1) choked on a piece of sausage during breakfast time. Staff (S1) gave the resident a regular diet food plate instead of mechanical soft diet plate. Hospice orders (3/2/25) state R1 requires a mechanical soft diet. This posed an immediate health, safety, and personal rights risk to the resient.
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Type B
07/08/2025
Section Cited
CCR
87469(c)(1)
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Advanced Directives and Requests Regarding Resuscitative Measures. Immediately telephone 9-1-1, present the advance directive and/or request regarding resuscitative measures form to the responding emergency medical personnel and identify the resident as the person to whom the order refers.
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Administration staff shall conduct staff training on Advance Directives and forms that need to be provided to emergency personnel at the time of an emergency.

Submit proof of staff training.

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Based on record review, on 6/15/25 staff called 911 regarding R1's choking incident. However, med-tech staff did not provide emergency personnel POLST or indentifying forms. This posed a potential health and safety 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.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025
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
06/20/2025 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250620120801

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: 76DATE:
06/26/2025
UNANNOUNCEDTIME BEGAN:
11:19 AM
MET WITH:Laura Sanchez, Health Services DirectorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not report resident's incident to appropriate parties.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit with Health Services Director Laura Sanchez.

The investigation consisted of: Record review, physical plant inspection of Memory Care Unit, interviews with staff (S1-S5) and residents (R1- R5). Copies of relevant documents pertaining to resident (R1) were obtained, as well as LIC 500 Personnel Report and resident roster.

*See next page for narrative.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025
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-20250620120801
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: 06/26/2025
NARRATIVE
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Allegation: Staff did not report resident's incident to appropriate parties. It is alleged that on Sunday, June 15, 2025, during breakfast time resident (R1) choked on a piece of sausage, and staff called 911 for emergency services. The complaint alleges that R1’s responsible party was notified via text at 10:27 AM requesting a call back, and hospice nurse received a call at 10:32 AM. Information obtained revealed that emergency personnel evaluated the resident and transported R1 to a local community hospital at approximately 9:48 AM. Staff interviews revealed that the choking incident occurred at approximately 9:00 AM, and a call to 911 emergency was made at 9:14 AM. After the incident staff called R1’s responsible party and immediately after the hospice nurse was notified of the incident and medical transport. According to staff interviews, at 10:25 AM, R1’s responsible party did not answer the call, a voice message was left, and a text was sent. The responsible party returned the call at 11:22 AM and finally spoke to them at 11:44 AM. Based on interviews conducted and copies of text and phone screen shots provided by facility, the findings indicate staff notified appropriate parties i.e., responsible party and hospice agency within a reasonable time. Therefore, there is insufficient evidence to corroborate the 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 allegations is Unsubstantiated.



Exit interview conducted with Human Resources Director Nadia Batista. A copy of the report was issued.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5