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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603710
Report Date: 08/05/2025
Date Signed: 08/05/2025 10:28:05 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
07/31/2025 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250731121504
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: 78DATE:
08/05/2025
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Tammy Garcia and Laura SanchezTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Staff did not fix the leak in the roof timely or properly.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra conducted an initial investigation to investigate the above allegation. LPA met with Tammy Garcia and discussed the purpose of today's visit. Laura Sanchez (Health Services Director) arrived at approximately at 8:45 A.M..

During this visit, LPA obtained a resident and staff roster, interviewed Staff #1 (S-1) through Staff #5 (S-5) and conducted a tour of the Memory Care Activity Room and Dining Room. During the tour of LPA observed ceiling tiles in the Memory Care Activity Room and Dining Room to have water damage.

Refer to LIC 9099C for the continuation of this report.



Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
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 3
Control Number 28-AS-20250731121504
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/05/2025
NARRATIVE
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Allegation: Staff did not fix the leak in the roof timely or properly. It has been alleged that the ceiling in the activity room has a leak and has not been fixed properly or in a timely manner. Staff interviews revealed that there is a leak in the Memory Care Activity Room and Dining Room. Interviewed staff indicated that ceiling leaks occur frequently during the Summer time as the HVAC (air conditioner) is being used. LPA toured the Memory Care Activity Room and Dining Room and observed ceiling tiles to have water damage. Interviews and tour corroborate this allegation.

Deficiency cited. Refe4r to LIC 9099D.

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

An exit interview was conducted. A copy of this report and appeals rights were provided to Laura Sanchez (Health Services Director).

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250731121504
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/12/2025
Section Cited
CCR
87303(a)
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Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
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Administrator to submit a written plan as to how the facility will maintain the ceiling tiles free of water damage and submit plan to LPA Irra by POC due date.
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This standard is not met at evidence by:

Interviewed staff indicated that ceiling leaks occur frequently during the Summer time as the HVAC (air conditioner) is being used. LPA observed water damage on ceiling tiles.
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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: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Elizabeth Irra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3