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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603710
Report Date: 09/30/2025
Date Signed: 09/30/2025 04:48:10 PM

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
09/23/2025 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250923141425
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: 81DATE:
09/30/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Stephanie Guerrero, LVNTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Licensee does not ensure that facility is kept in good repair.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Cynthia Chan and Elena Mallett conducted a complaint investigation for the allegation listed above. LPAs arrived unannounced and met with Staff, Stephanie Guerrero. The reason for the visit was explained.

LPAs obtained copies of the staff and resident rosters, inspected 10 resident rooms, and the laundry rooms. Interviews were held with Staff #1-#5 and Residents #1-#10.

The investigation revealed the following:
Allegation – Licensee does not ensure that the facility is kept in good repair. It is alleged that there are ceiling leaks, and the washer has been broken for months. LPAs interviewed five (5) staff today. Staff stated the past leaks in the ceiling were repaired, and there are no current leaks they are aware of. Staff stated that if they observe anything in disrepair, they will inform maintenance right away.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
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-20250923141425
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: 09/30/2025
NARRATIVE
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The facility has recently implemented a laundry service and is using the industrial washing and drying machines. In addition, the facility has available washers and dryers for residents to use. Staff stated the washing machine currently working is located on the 3rd floor. LPAs interviewed ten (10) residents. Two (2) of the residents stated there were water leaks in their rooms, however, staff had repaired them. Nine (9) out of ten (10) residents stated the facility does their laundry once a week. During the walk through, LPAs selected ten (10) resident rooms to inspect. There were no leaks observed on the ceiling. LPAs also checked the laundry rooms. The washer in the memory care unit did not appear operable, and staff confirmed it is not working. The facility currently has one (1) functioning washing machine available for resident to use at this time. Staff stated it had repeatedly been broken down.

Based on LPA observations and interviews conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D.

An exit interview was conducted. The Plan of Correction was reviewed and developed with House Service Director, Laura Sanchez. A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250923141425
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: 09/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/17/2025
Section Cited
CCR
87303(g)(1)
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87303 Maintenance and Operation (g) Facilities which have machines and do their own laundry shall: (1) Have adequate supplies available and equipment maintained in good repair.
This requirement is not met as evidenced by:
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The licensee shall submit a plan to ensure all the washers are operable for staff and residents to use. This plan is due to LPA by 10/17/25.
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Based on interviews and observation, the washing machine in the memory care unit is not operable which poses a potential health and safety and personal rights to residents 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.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3