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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603710
Report Date: 08/07/2025
Date Signed: 08/07/2025 03:34:11 PM

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
11/19/2024 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20241119083111
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: 80DATE:
08/07/2025
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Laura SanchezTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Resident pull cords are in disrepair
Staff did not ensure leaks were fixed timely
Staff did not ensure alarmed exit doors work properly at all times
Residents have unexplained bruises
Due to lack of supervision, resident eloped
Staff are not reporting incidents to authorized representatives
Staff do not safeguard residents personal property
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced subsequent complaint visit to investigate the above mentioned allegations and to deliver findings.
LPA met with Laura Sanchez Health Services Director and explained the reason for the visit.
The initial visit was conducted on 11/26/2024 and the following was done:
LPA Trueman requested copies of the staff and resident rosters, and explained the reason for the visit. LPA interviewed Laura Sanchez Health Services Director, Staff 1 - Staff 3 (S1 - S3) and Resident R1.
LPA also toured common areas in memory care. In memory care Rooms 160,161, 163, 164, 165, and 182 were inspected.
At today's visit 08/07/2025 Resident's R 2-9 were interviewed.
Staff S4 was interviewed.
In regards to the allegation Resident pull cords are in disrepair, based on facility tour conducted on 11/26/2024, interviews conducted and information gathered it was revealed that in memory care tour of Rooms 160,161, 163, 164, 165, and 182 all were inspected and all were in good repair. Response time
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
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-20241119083111
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: 08/07/2025
NARRATIVE
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was immediate.
Staff stated that once the pull cord is pulled it will go to any staff who has a pager. Pager gives the location.
Interview with Resident R1 who stated that the pull cord is working and staff always assist right away.
Resident's R2-R9 stated the pull cord is working well and response time is quick.
It should also be noted that findings were delivered 05/13/2025 for Staff do not answer resident's calls for assistance timely. This allegation was Unsubstantiated.
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 did not ensure leaks were fixed timely, based on facility tour, interviews and information gathered it was observed by the LPA tour on the initial visit 11/26/2024 that there were no leaks.
Interview with Health Services Coordinator Laura Sanchez who stated that. any leak is fixed right away.
Staff S2 stated that any leaks are fixed within the hour and said they hadn't had one in awhile.
Interview with Staff S3 who is Maintenance Director who stated that there are no leaks he is aware of and if there was you would see them now.
Interview with Resident's R1- R 9 who all stated they didn't observe any leaks.
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 did not ensure alarmed exit doors work properly at all times, the complaint findings dated 12/10/2024 were previously addressed with Substantiated findings by LPA Pena. COMPLAINT CONTROL NUMBER: 28-AS-20241001133551.
It notes that S1 stated that what she thinks happened was that R1 went out the back gate and the alarm did not go off. S1 showed LPA how the back gate’s alarm work and it involved 4 steps to secure the gate. S1 indicated that someone must have missed a step or two in locking it, hence the alarm failed to go off. LPA observed that the back gate leads to a driveway towards the main road next to the freeway.
The facility rosters dated 10/03/2024 specified a total of 19 memory care residents including R1, 7 caregivers and 3 med techs assigned on different shifts in the memory care unit. However, when R1 wandered away from the facility on 9/30/2024, there were only (2) caregivers and (1) med tech working. Therefore, there was sufficient evidence to corroborate the allegation of lack of supervision which led to R1 wandered from the facility.

Based on LPA’s observations and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

It should be noted no deficiency issued at today's visit. Prior investigation on 09/30/2024 and 10/3/24 LPA Pena Substantiated and issued deficiency.



In regards to the allegation Residents have unexplained bruises based on interviews conducted and information gathered Resident's R1- R9 all stated they do not have unexplained bruises and have not seen anyone with Unexplained bruises. Also stated that staff have not told them to cover up bruises.
Staff stated that they had not covered up residents bruising.
Said if skin tear they may wear a hospital protective sleeve, but never anything malicious.
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.



SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20241119083111
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: 08/07/2025
NARRATIVE
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In regards to the allegation Due to lack of supervision, resident eloped, the complaint findings dated 12/10/2024 were previously addressed with Substantiated findings by LPA Pena.
It notes the following that S1 stated that what she thinks happened was that R1 went out the back gate and the alarm did not go off. S1 showed LPA how the back gate’s alarm work and it involved 4 steps to secure the gate. S1 indicated that someone must have missed a step or two in locking it, hence the alarm failed to go off. LPA observed that the back gate leads to a driveway towards the main road next to the freeway.
The facility rosters dated 10/03/2024 specified a total of 19 memory care residents including R1, 7 caregivers and 3 med techs assigned on different shifts in the memory care unit. However, when R1 wandered away from the facility on 9/30/2024, there were only (2) caregivers and (1) med tech working. Therefore, there was sufficient evidence to corroborate the allegation of lack of supervision which led to R1 wandered from the facility.

Based on LPA’s observations and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

It should be noted no deficiency issued at today's visit. Prior investigation on 09/30/2024 and 10/3/24 LPA Pena Substantiated and issued deficiency.


In regards to the allegation Staff are not reporting incidents to authorized representatives, based on interviews conducted and information gathered it was revealed by Health Services Coordinator Laura Sanchez that all incidents are always reported to Licensing.
Special Incident Reports (SIR's) were submitted 09/30/2024 and 12/01/2024 both concerning the elopement of 2 residents.
Incident reported 09/30/2025 states that resident was located by Highway Patrol off of the 57 entrance.
Staff were able to bring the resident back.
On the 12/01/2025 report the resident was across the street walking on the sidewalk and walking back to the facility.
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 safeguard residents personal property, based on interviews conducted and information gathered Resident's R1- R9 all stated they have never had any items stolen from their rooms.
Said housekeeping does a good job.
All stated staff are nice and helpful.
Staff stated that Resident R1 or family never reported any items missing and they have a Personal Inventory List to ensure documentation of all resident's belongings.
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.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Glenn Trueman
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3