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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603710
Report Date: 12/02/2025
Date Signed: 12/02/2025 03:46:23 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
11/25/2025 and conducted by Evaluator Erik Zaragoza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20251125113714
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: 83DATE:
12/02/2025
UNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Stephanie Guerrero - Wellness NurseTIME COMPLETED:
04:04 PM
ALLEGATION(S):
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Staff did not obtain medical care for resident in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an initial unannounced complaint visit to investigate the allegation listed above. LPA met with Stephanie Guerrero, Wellness Nurse for the facility, and explained the purpose of the visit.

The investigation consisted of the following: During today's visit LPA interviewed Staff #1 - 3 (S1 - S3), Residents #1 - 5 (R1 - R5), and also obtained the physician's report, service plan, assessments, Emergency Identification information, discharge paperwork, and physician's report for R1.

The investigation revealed the following: In regards to the allegation that "Staff did not obtain medical care for resident in a timely manner," it was alleged that on 11/23/2025 there was a delay in transporting R1 to the hospital after it was revealed that they required medical attention at 7:00 PM.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
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-20251125113714
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BAYSHIRE SAN DIMAS
FACILITY NUMBER: 198603710
VISIT DATE: 12/02/2025
NARRATIVE
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During interviews with the residents, three (3) out of five (5) interviewed did not corroborate the allegation. One resident interviewed stated that they recently required hospitalization, and that staff assisting them in obtaining medical care in a timely and prompt manner. Another resident interviewed stated that they staff have assisted them in an adequate time frame when they have required medical assistance. During interviews with staff, none of them corroborated the allegation. One of the staff interviewed stated that they became aware that R1 required medical attention on 11/23/2025 and contacted their hospice agency at around 11:00 PM to ask if they would be able to send a nurse to see the resident, however after an hour the hospice agency indicated they would not arrive until 8:00 AM on 11/24/2025, and at this time it was decided an ambulance would be called to take R1 to the hospital. Another staff interviewed also confirmed that a private ambulance was called at 11:00 PM per R1's request, and was sent to the hospital afterwards. Progress notes indicate that R1 was sent out to the hospital via private ambulance at 2:36 AM on 11/24/2025.

Based on statements and interviews conducted with staff, residents, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview held, and a copy of this report along with appeal rights were provided to the administrator.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
11/25/2025 and conducted by Evaluator Erik Zaragoza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20251125113714

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: 83DATE:
12/02/2025
UNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Stephanie Guerrero - Wellnness NurseTIME COMPLETED:
04:04 PM
ALLEGATION(S):
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9
Staff do not follow reporting requirements
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Erik Zaragoza conducted an initial unannounced complaint visit to investigate the allegation listed above. LPA met with Stephanie Guerrero, Wellness Nurse for the facility, and explained the purpose of the visit.

The investigation consisted of the following: During today's visit LPA interviewed Staff #1 - 3 (S1 - S3), Residents #1 - 5 (R1 - R5), and also obtained the physician's report, service plan, assessments, Emergency Identification information, discharge paperwork, and physician's report for R1.

The investigation revealed the following: In regards to the allegation that "Staff do not follow reporting requirements," it was alleged that after R1's hospitalization on 11/24/2025, staff did not notify the resident's family of the incident.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20251125113714
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: BAYSHIRE SAN DIMAS
FACILITY NUMBER: 198603710
VISIT DATE: 12/02/2025
NARRATIVE
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During interviews with the residents, one (1) out of five (5) corroborated the allegation. One resident interviewed stated that they were hospitalized and that their family was not notified of the visit until the family had called the facility the following day. During interviews with the staff, none of them corroborated the allegation. S1 stated that S3 called the primary relative of R1 following the incident on 11/24/2025 at 2:00 AM, however they are unsure if the contact was reached. S3 stated that they attempted calling family relatives of R1, however the call went to voicemail, and they cannot recall if they ever called back. During record review before the visit, LPA observed that no serious incident reports (SIRs) have been submitted to Community Care Licensing Division (CCLD). An SIR was provided to LPA during the visit dated 12/2/2025, however this is eight (8) days after the occurrence of the incident, which exceeds the seven (7) day time-frame required per Title 22 regulations.

Based on LPA interviews conducted with the residents and staff, the preponderance of evidence standard has been met for the above allegations, therefore the allegation is found to be SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 is being cited on the attached LIC9099D page.

Exit interview was held and a copy of the report along with the appeal rights were provided.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20251125113714
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 12/02/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/05/2025
Section Cited
CCR
87211(a)(1)(D)
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(a) Each licensee shall furnish to the licensing agency such reports (...) including, but not limited to, the following: (1) A written report (...) within seven days of occurance (...) (D) Any incident which threatens the welfare, safety or health (...) of any resident.
This regulation is not met as evidenced by:
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***POC Cleared*** Licensee is to ensure that incident reports for all incidents that threaten the health and safety of residents are submitted within the required timeframe. Administrator is to provide an incident report for the related incident to the LPA by the POC due date.
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Based on interview and record review, LPA determined that an incident report was not submitted to the licensing agency within the required timeframe, which poses a potential health and safety risk 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: David Sicairos
LICENSING EVALUATOR NAME: Erik Zaragoza
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5