Inspection Reports for San Dimas Retirement

The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 07/15/2025 regarding unlawful eviction, harassment, document safeguarding, call button response, mail handling, food service adequacy, and transportation coordination at the facility.

The investigation found no preponderance of evidence to substantiate the allegations. Administrators and staff denied the allegations, and interviews with residents supported timely staff responses and adequate services. The eviction was supported by documented behavioral issues, and no evidence was found of mail tampering or inadequate food service. Transportation coordination was confirmed by staff and most residents.

The complaint investigation addressed seven allegations: unlawful eviction, failure to prevent harassment, failure to maintain citizenship documents, delayed staff response to call buttons, opening residents' mail, inadequate food service, and failure to coordinate transportation. All allegations were found unsubstantiated due to lack of sufficient evidence.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not seek timely medical care for a resident and did not ensure the resident's medical equipment was maintained in operable condition.

The investigation found that staff called 911 within 2 to 5 minutes of the resident's emergency call and assisted promptly, with most residents confirming timely care. The resident manages their own breathing treatment and medication, and staff provided a loaner breathing machine after the resident's equipment broke down. Staff and resident interviews and record reviews did not corroborate the allegations, resulting in the complaints being unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included delayed medical response and failure to maintain medical equipment. Interviews and evidence showed timely emergency response and provision of a loaner breathing machine. The resident manages their own medication and declined staff assistance with ordering supplies. There was no preponderance of evidence to prove violations.

An unannounced complaint investigation visit was conducted regarding an allegation that facility staff are not preventing a resident from harassing other residents.

The investigation found that resident R4 exhibited inappropriate behaviors such as making inappropriate comments, yelling, and blocking access to parts of the facility. Staff intervened and addressed these behaviors. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that facility staff were not preventing a resident from harassing other residents. Interviews with staff and residents, review of incident reports, and other documentation revealed that while R4 exhibited inappropriate behavior, staff intervened appropriately. The allegation was unsubstantiated.

An unannounced complaint investigation visit was conducted in response to an allegation that staff did not prevent an altercation between residents in care.

The investigation found that although verbal altercations between residents occur, staff take measures to prevent escalation and intervene appropriately. Staff and resident interviews did not corroborate the allegation, and the complaint was determined to be unsubstantiated.

The allegation was that staff witnessed an incident where residents were shouting and using racial slurs and did not prevent the altercation. Staff denied the allegation and stated they intervene to prevent escalation. Resident interviews supported that staff take measures to manage verbal altercations. The allegation was unsubstantiated due to lack of preponderance of evidence.

The visit was an unannounced complaint investigation conducted in response to an allegation that staff did not ensure a resident was allowed to be readmitted to the facility.

The investigation included interviews and document reviews and found insufficient evidence to substantiate the allegation. The resident was confirmed to be residing in the memory care unit, and the allegation was determined to be unsubstantiated.

The complaint alleged that staff did not ensure a resident was allowed to be readmitted to the facility. The allegation was unsubstantiated due to insufficient evidence.

An unannounced complaint investigation was conducted regarding allegations that staff do not ensure smoke detectors in resident rooms are operating properly.

The investigation found that three out of six smoke detectors on the second floor were not working at the time of the visit, posing an immediate health and safety risk. Work orders had been submitted to address the issue, and residents reported no issues with smoke detectors.

The complaint alleging that staff do not ensure smoke detectors in resident rooms are operating properly was substantiated based on observations and interviews. The preponderance of evidence standard was met.

An unannounced complaint investigation visit was conducted regarding an allegation that facility staff were not preventing a resident from harassing other residents.

The investigation included interviews with seven residents and three staff members, as well as a review of resident records. No evidence was found to corroborate the allegation, and the complaint was determined to be unsubstantiated due to lack of preponderance of evidence.

The allegation was that facility staff were not preventing resident R4 from harassing other residents. Interviews and records review did not corroborate the allegation. The complaint was unsubstantiated.

An unannounced complaint investigation visit was conducted due to an allegation that staff were not safeguarding residents' personal belongings.

The investigation found insufficient evidence to substantiate the allegation. Interviews with staff and residents, review of records, and video footage did not corroborate claims of missing items or unsecured rooms. The allegation was determined to be unsubstantiated.

The complaint alleged that staff were not safeguarding residents' personal belongings, specifically that Resident #1 had items missing and that her door was left unlocked. The investigation included interviews with staff and residents, review of training and policies, and video footage review. No evidence was found to support the allegation, and it was deemed unsubstantiated.

The visit was a required, unannounced annual inspection to evaluate compliance with licensing regulations for the San Dimas Retirement Center.

The Licensing Program Analyst conducted a thorough review of the facility, including resident rooms, medication storage, food supply, and staff and resident records. No deficiencies were observed during the visit, and the facility met all regulatory requirements.

The visit was an unannounced complaint investigation triggered by an allegation that staff did not distribute a resident's medication as prescribed.

The investigation substantiated the allegation that on 12/31/2024, a resident (R-1) was not provided pain medication as prescribed. Documentation showed medications were administered in less than the ordered 8-hour interval and the medication log lacked required details such as reason and result of administration.

The complaint was substantiated based on interviews and document review. The allegation involved failure to distribute resident's medication as prescribed on 12/31/2024. Four out of six staff recalled the resident's request but could not specify date/time. Two out of five residents reported not receiving requested PRN medications.

An unannounced complaint investigation visit was conducted regarding allegations that facility staff left residents in urine-soaked clothing for an extended period and did not provide residents with linens in good clean condition.

The investigation found that all interviewed residents and staff denied the allegations. Observations showed residents were well groomed, clothing and linens appeared clean, and resident rooms were not malodorous. There was no preponderance of evidence to substantiate the allegations, and no violations were observed.

The complaint was unsubstantiated. Ten residents and seven staff members denied the allegations. Observations during the investigation supported these denials, and no violations were found.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff refused resident access to personal belongings, did not safeguard belongings, and did not accord privacy to the resident.

The investigation found insufficient evidence to substantiate the allegations. Interviews with staff and residents, record reviews, and observations indicated that the facility followed safety protocols, residents had access to their belongings, and privacy was respected. The allegations were determined to be unsubstantiated.

The complaint involved three allegations: 1) staff refusing resident access to personal belongings due to room clutter, 2) staff not safeguarding resident's personal belongings, and 3) staff not according privacy to the resident. The investigation included interviews with staff, residents, and administrators, review of resident files and training logs, and observations. The allegations were found unsubstantiated.

An unannounced complaint investigation was conducted in response to an allegation that staff did not allow a resident to fully participate in planning their care, specifically regarding the prescription of a second psychiatric medication against the resident's wishes.

The investigation included interviews with staff and residents and a review of records. Most staff and residents denied the allegation, and there was insufficient evidence to substantiate the claim that staff lied to the resident or prevented participation in care planning. The allegation was determined to be unsubstantiated.

The complaint alleged that staff did not allow the resident to fully participate in planning their care, including prescribing a psychiatric medication against the resident's wishes. Interviews with four staff and ten residents found no corroboration. The resident was inconsistent in statements and no evidence supported the allegation. The complaint was unsubstantiated.

This was an unannounced complaint investigation visit triggered by allegations received on 07/22/2024 concerning staff neglect and improper care of a resident at San Dimas Retirement Center.

The investigation substantiated multiple allegations including staff leaving a resident unattended after a fall, failure to ensure a resident's alert device was operational, failure to properly report the incident to the resident's authorized representative, overcharging for services not received, and the resident sustaining unexplained injuries including a hip dislocation. Deficiencies were cited related to inadequate supervision, faulty signal systems, failure to notify responsible parties, and failure to comply with admission agreements.

The complaint investigation was substantiated. Allegations included staff leaving a 95-year-old resident unattended after a fall on 7/17/2024, failure to ensure the resident's alert device was working, failure to notify the resident's authorized representative promptly, overcharging for personal care services not received, and the resident sustaining a hip dislocation requiring surgery. The resident was discharged after the second surgery on 8/30/2024.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2024-06-20 alleging insufficient staffing to meet resident needs and other related concerns.

The investigation substantiated the allegation that the facility does not have sufficient staff to meet resident needs, posing potential health and safety risks. Other allegations regarding medication administration, hygiene, room cleaning, laundry, mold, pests, and urine odor were found to be unsubstantiated based on interviews, observations, and document reviews.

The complaint alleged insufficient staffing to meet resident needs, which was substantiated based on interviews with staff and residents confirming staffing shortages and related stress. Other allegations about medication delays, hygiene neglect, room cleaning, laundry issues, mold presence, pest infestations, and urine odor were investigated and found unsubstantiated due to lack of sufficient evidence.

The visit was conducted as a Case Management - Deficiencies inspection due to observations made while investigating a complaint (control #: 28-AS-20240722091157).

The Licensing Program Analyst observed three medication pill bottles in a resident's room and found the resident confused about medication names and dosages, posing an immediate health and safety risk. A deficiency was cited for failure to centrally store hazardous medications as required.

The visit was triggered by a complaint investigation (control #: 28-AS-20240722091157).

The inspection was an unannounced complaint investigation visit conducted to investigate an allegation of illegal eviction at the facility.

The investigation found that the allegation of illegal eviction was unsubstantiated. Staff interviews and record reviews indicated the resident was discharged to a hospital for a higher level of care with appropriate physician orders and discharge paperwork signed by the resident's POA.

The complaint alleged that the facility illegally evicted a resident by discharging them to a hospital without issuing a 30-day eviction notice and then refused to accept the resident back. The allegation was found unsubstantiated due to insufficient evidence.

An unannounced complaint investigation was conducted to investigate the allegation that the facility is not ensuring that resident's transportation needs are being met while in care.

The investigation included interviews with staff and residents, review of resident records, and observation. The allegation that the facility failed to meet a resident's transportation needs was found to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that Resident #1 required a larger vehicle for transportation to medical appointments but did not receive it, resulting in missed appointments. Staff denied the allegation, stating transportation arrangements were made and larger vehicles requested, but the resident refused smaller vehicles. Resident admitted to refusing transportation due to safety concerns. Resident and other residents confirmed transportation was generally arranged appropriately.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-03-27 regarding staff not addressing healthcare needs, leaving residents in soiled clothing, and not providing fresh clean linens.

The investigation included interviews with residents and staff, facility tours, and record reviews. The findings did not substantiate the allegations; residents and staff denied the claims, observations showed residents were clean and well cared for, and records supported proper care practices.

The complaint investigation was unsubstantiated. Allegations included staff failing to address healthcare needs, leaving residents in soiled clothing for extended periods, and not providing fresh linens. Interviews and observations did not corroborate these claims.

The visit was an unannounced complaint investigation conducted to investigate an allegation that staff did not provide adequate supervision resulting in a resident speaking to another resident in an inappropriate manner.

The investigation found that although the verbal altercation between residents did occur, there was insufficient evidence to prove that it resulted from inadequate staff supervision. No deficiencies were observed or cited during the visit, and the allegation was determined to be unsubstantiated.

The complaint alleged that on 3/18/24, Resident 1 was playing loud music in the dining room, which upset Resident 2, leading to Resident 2 yelling profanities at Resident 1. Staff interviews confirmed the verbal altercation but denied it was due to lack of supervision. Resident interviews corroborated the incident but stated no staff were present. Management was aware of ongoing issues between the two residents. The incident was reported to licensing on 3/20/24. The allegation was unsubstantiated due to lack of preponderance of evidence.

The inspection was an unannounced required annual inspection conducted to evaluate the facility using the Compliance and Regulatory Enforcement (CARE) Tool.

The inspection found the facility to be in compliance with no deficiencies observed or cited. Resident rooms, bathrooms, food supplies, fire safety equipment, and documentation were all found to meet regulatory requirements.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-05-23 regarding inadequate food service, poor food quality, insufficient staffing, medication administration issues, and unmet hygiene needs at the facility.

The investigation found no substantiated evidence to support the allegations. Interviews with staff, residents, and review of records indicated adequate food service and quality, sufficient staffing, proper medication administration, and appropriate assistance with hygiene needs. Residents largely corroborated these findings.

The complaint investigation was unsubstantiated. Allegations included inadequate food service, poor food quality, insufficient staffing, residents not receiving medication as prescribed, and unmet hygiene needs. The investigation included interviews with staff and residents, review of food supply, staff roster, and medication records. No deficiencies were cited.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-03-14 regarding allegations of unexplained injury to a resident, denial of access to resident records, and failure to report incidents to appropriate parties.

The investigation substantiated all allegations: a resident sustained an unexplained injury due to a fall with inadequate assessment and delayed medical attention; staff denied authorized representatives access to resident records; and the facility failed to timely report incidents to the Ombudsman and licensing agency as required.

The complaint investigation was substantiated. Allegations included unexplained injury to a resident from a fall on 09/25/2022, denial of access to resident records to authorized representatives including the Ombudsman and resident's daughter, and failure to report incidents to appropriate parties. The facility failed to properly assess injuries, delayed hospital transfer, denied record access citing legal advice, and delayed reporting incident reports until 10/25/2022.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2023-07-24 regarding allegations of resident fall, delayed medical attention, and delayed staff response.

The investigation found no preponderance of evidence to substantiate the allegations. The resident fell due to a wheelchair brake failure, not staff neglect. Medical attention was offered and eventually provided, and staff response times could not be proven deficient.

The complaint alleged that a resident fell sustaining a fracture, staff did not seek timely medical attention, and staff did not respond timely to a call light. Interviews and document reviews found no evidence to substantiate these allegations. The resident admitted the wheelchair brakes were broken and that the fall was not due to staff neglect. Staff stated the resident initially refused hospital transport but was later taken to the hospital. No evidence supported delayed response to call light.

An unannounced complaint investigation visit was conducted to investigate allegations that staff did not ensure a resident had a clean mattress and that a resident's toilet was in disrepair.

The investigation found insufficient evidence to substantiate the allegations. Staff and residents denied the claims, and observations showed the mattress and toilet were in acceptable condition or promptly repaired. Therefore, the allegations were deemed unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included a resident not having a clean mattress and a resident's toilet being in disrepair, including claims of using a garbage bag over a pail as a toilet. Staff and resident interviews, as well as observations, did not support these claims.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 08/15/2022 regarding staff behavior, food service adequacy, fairness in resident treatment, and staff retaliation at the facility.

The investigation included interviews with staff and residents and a tour of the facility. All allegations were found to be unsubstantiated due to insufficient evidence or denial by staff and residents. Most residents reported respectful treatment and adequate food service.

The complaint involved allegations that staff behavior posed a risk to a resident, inadequate food service was provided, residents were not treated fairly, and staff retaliated against a resident. Interviews with 13 residents and 6 staff members, including the Administrator and Assistant Administrator, did not substantiate these allegations. The report concluded there was insufficient evidence to prove the alleged violations occurred.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were committing tax identity theft using residents' personal information.

The investigation included interviews with staff and residents, a tour of the facility, and review of records. No evidence was found to substantiate the allegation that staff claimed residents as tax dependents. The allegation was determined to be unsubstantiated due to lack of supporting evidence.

The complaint alleged that a staff member was claiming a resident on their taxes as a dependent. Interviews with 8 staff and 13 residents denied or could not corroborate the allegation. File reviews and observations did not provide proof of the allegation. The complaint was unsubstantiated.

The inspection was an unannounced complaint investigation visit conducted to ascertain the validity of allegations including staff stealing resident belongings, failure to change urine-soaked bedding, and failure to ensure fall risk measures were in place.

The investigation found the first three allegations unsubstantiated based on interviews and document reviews. However, the allegation that the facility was odoriferous was substantiated due to an overwhelming smell of urine and mildew in a resident's room, indicating failure to keep the facility free of odors from incontinence.

The complaint investigation was triggered by allegations of staff stealing resident belongings, failure to change urine-soaked bedding, failure to ensure fall risk measures, and facility odor issues. The first three allegations were unsubstantiated, while the odor allegation was substantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2021-12-22 regarding insufficient staff to meet residents' needs, non-compliance with Covid-19 safety protocols, and untimely response to residents' requests for assistance.

The investigation found that during the period of the allegations, the facility experienced staffing challenges due to Covid-19 infections but utilized staff registries and cross-trained staff to meet resident needs. Interviews with residents and staff largely denied the allegations. Covid-19 protocols were observed to be followed, and call light response times were timely. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unsubstantiated. Allegations included insufficient staffing, failure to follow Covid-19 protocols, and delayed response to resident assistance requests. Interviews with staff and residents, facility tours, and call light testing did not substantiate the allegations.

The visit was an unannounced complaint investigation triggered by allegations that the facility failed to provide proper notice of rate increases to SSI residents and raised monthly rent for an SSI resident.

The investigation found that the facility provides proper notice of rate increases to SSI recipients and their responsible parties, supported by staff and resident interviews and documentation. The allegation that the facility raised rent for SSI residents was denied by staff and residents, with the Administrator stating that rate increases are controlled by the Assisted Living Waiver Program, not the facility. The allegations were unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unsubstantiated. Allegations included failure to provide proper notice of rate increases and raising monthly rent for an SSI resident. Staff and residents confirmed proper notice was given, and rate increases are controlled externally by the Assisted Living Waiver Program.

An unannounced complaint investigation was conducted in response to allegations received on 2022-08-08 regarding facility conditions, staff assistance timeliness, food quality, and resident care.

The investigation found insufficient evidence to substantiate the allegations. Residents and staff interviews, observations, and file reviews indicated that carpets were replaced with laminate flooring, staff responded timely to call buttons, food was nutritious, and residents were not left in soiled diapers.

The complaint investigation was unsubstantiated based on observations, interviews with residents and staff, and file reviews. Allegations included facility carpets in disrepair, untimely staff assistance, poor food quality, and residents left in soiled diapers, none of which were supported by sufficient evidence.

An unannounced complaint investigation visit was conducted regarding an allegation that staff denied a resident a snack in between meals.

The investigation found that 9 out of 10 residents stated snacks are provided throughout the day, and staff interviews indicated residents are generally redirected to available snacks. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that staff denied a resident two slices of bread to make a sandwich. Interviews with residents and staff, as well as observation of snacks available, were conducted. The allegation was found unsubstantiated.

Unannounced complaint investigation visit conducted due to allegations including staff hitting a resident, inadequate food service, and failure to ensure a resident was served food.

The investigation found no preponderance of evidence to substantiate the allegations. Video footage, interviews with residents and staff, and law enforcement records did not support claims of staff hitting residents or failing to provide adequate food service.

Allegations included staff hitting a resident, not providing adequate food service, and not ensuring a resident was served food. The complaint was unsubstantiated based on interviews, video review, and law enforcement records.

An unannounced complaint investigation visit was conducted in response to allegations received on 03/22/2023 regarding staff hitting a resident and inadequate food service to a resident.

The investigation found no evidence to substantiate the allegations. Video footage and staff interviews showed no staff hitting the resident, and food was provided to the resident as alleged. Therefore, the allegations were unsubstantiated.

The complaint included allegations that staff hit a resident and failed to provide adequate food service. The investigation included interviews, video review, and observations. The allegations were found unsubstantiated due to lack of preponderance of evidence.

The inspection was an unannounced complaint investigation regarding allegations that staff were not preventing a resident from verbally abusing another resident and that staff failed to report the incident to appropriate agencies.

The investigation found that the facility intervened in a timely manner to prevent escalation of the verbal abuse incident, and the allegations were unsubstantiated due to lack of preponderance of evidence. The incident was reported to the appropriate agencies within the required timeframe.

The complaint involved allegations that staff did not prevent resident R12 from verbally abusing resident R1 and failed to report the incident to appropriate agencies. The investigation revealed that the facility addressed the situation promptly, residents refused mediation or room changes, police were involved but did not file a report, and the incident was reported to CCLD and ombudsman on 03/08/2023. The allegations were unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2022-05-20 regarding inadequate food service, disrespectful staff behavior, and unmet medical needs of residents.

The investigation found no preponderance of evidence to substantiate the allegations. Most residents interviewed did not corroborate the complaints, and facility staff denied the allegations. The facility demonstrated efforts to address concerns, including dietary guidance and attempts to manage medical referrals.

The complaint involved three main allegations: inadequate food service, staff disrespect towards residents, and failure to meet a resident's medical needs. The investigation included interviews with staff and residents, review of menus and nurse notes, and found the allegations unsubstantiated due to lack of sufficient evidence.

Licensing Program Analyst Maldonado conducted an unannounced visit to the facility for the purpose of conducting the annual required inspection.

The inspection included evaluation of infection control, facility plant, COVID-19 procedures, staff and resident files, medications, and food supplies. Deficiencies were found related to missing proof of required annual training certification in 5 of 7 staff files, posing potential health and safety risks.

An unannounced complaint investigation visit was conducted to determine the validity of multiple allegations received on 08/09/2022 regarding staff conduct and facility operations at San Dimas Retirement Center.

The investigation found no preponderance of evidence to substantiate the allegations, which included interference with resident visiting, medication distribution issues, delayed response to call buttons, inappropriate staff behavior, unmet dietary needs, poor communication with responsible parties, uncomfortable facility temperature, and failure to follow bath schedules. Residents and staff interviews did not corroborate the complaints.

The complaint investigation was unsubstantiated. Allegations included staff interfering with resident visits, medication distribution delays, untimely response to call buttons, inappropriate staff communication, unmet dietary needs, lack of communication with responsible parties, uncomfortable facility temperature, and failure to follow bath schedules. Interviews with residents and staff did not support these allegations.

The inspection visit was an unannounced complaint investigation triggered by an allegation that staff did not prevent a resident from wandering away from the facility.

The investigation found that although there were issues with a resident attempting to leave the facility multiple times, the resident in question was not confirmed to be a current resident. Staff took multiple measures to prevent the resident from leaving unassisted, including frequent checks, changing gate codes, and one-to-one supervision. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that staff did not prevent a resident from wandering away from the facility. The investigation revealed that the resident identified in the allegation was not a current resident, and staff were vigilant in monitoring and attempting to prevent the resident from leaving. The allegation was unsubstantiated.

The inspection was an unannounced complaint investigation conducted in response to allegations received on 2022-10-26 regarding inadequate staffing, inadequate food service, lack of activity schedule, and pest infestation at the facility.

The investigation found that staffing levels were generally sufficient with some resident concerns, food service had mixed feedback with some residents noting cold food and repetition but others noting improvement, activities were held daily and residents were encouraged to participate, and no significant pest infestation was observed with pest control services in place. Overall, the allegations were unsubstantiated due to lack of preponderance of evidence.

The complaint investigation was unsubstantiated. Allegations included inadequate staffing, inadequate food service, lack of activity schedule, and pest infestation. Interviews and observations did not support the allegations sufficiently to substantiate violations.

The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility elevator is not in good operating condition.

The investigation found that although there was an allegation of elevator malfunction causing injury, the elevators were tested and found to have functioning sensors and no evidence of disrepair. Interviews with staff, residents, and an elevator company representative supported that the elevators operate properly. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that a person reached in with one hand to stop the elevator door from closing but ended up crushing the hand, and that the older elevators lack infrared motion detection. The investigation included interviews with the Administrator, Assistant Administrator, staff, residents, and an elevator company representative, as well as testing of the elevators and review of service reports. The allegation was found unsubstantiated.

The inspection was conducted as an unannounced complaint investigation regarding the allegation that the facility elevator is not in good operating condition.

The investigation found that the elevators have sensors and appear to work properly based on observation, interviews, and review of service reports. The allegation that a person was injured by the elevator door was unsubstantiated due to lack of evidence.

The complaint alleged that the facility elevator was not in good operating condition and that a person had injured their hand trying to stop the elevator door from closing. After investigation including interviews with staff, residents, and an elevator company representative, and testing of the elevators, the allegation was determined to be unsubstantiated.

The inspection was an unannounced complaint investigation visit conducted to investigate allegations including illegal eviction of a resident, failure to prevent a resident from leaving the facility without authorization, and failure to report an incident to Community Care Licensing and the resident's family.

The investigation substantiated that the resident was illegally evicted without proper notice and that staff failed to prevent the resident from leaving the secured memory care unit unassisted on multiple occasions. The allegation that the facility failed to report an incident to Community Care Licensing and the resident's family was unsubstantiated.

The complaint investigation was substantiated for allegations that Resident #1 was illegally evicted and that staff failed to prevent the resident from AWOL'ing from the facility. The allegation that the facility failed to report the incident to Community Care Licensing and the resident's family was unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff do not treat residents with respect and speak inappropriately in front of residents.

The investigation substantiated that some staff did not treat residents with respect, as evidenced by resident interviews and observations. However, the allegation that staff spoke inappropriately in front of residents was unsubstantiated. Additionally, it was found that staff training was insufficient, with most staff not having completed required annual training hours.

The complaint alleged that staff do not treat residents with respect and speak inappropriately in front of residents. The allegation regarding disrespectful treatment was substantiated based on interviews with residents and staff, while the allegation regarding inappropriate speech was unsubstantiated due to lack of evidence.

The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that the facility has insects causing residents to get bug bites at night inside their bedrooms.

The investigation found no preponderance of evidence to substantiate the allegation. Staff and administrator denied the allegation and reported ongoing communication and pest control measures. Resident interviews were mixed, with most unable to corroborate the claim. Pest control reports showed no pest activity. The allegation was determined to be unsubstantiated.

The complaint alleged that a resident was getting bug bites at night inside their bedroom and that the facility had not communicated with the resident to resolve the issue. The allegation was unsubstantiated after investigation.

The inspection was an unannounced complaint investigation regarding the allegation that the facility elevator is not in good operating condition.

The investigation found that the elevator sensors did not detect objects placed at the last seconds before the doors closed, posing a potential safety hazard. Interviews with staff and residents mostly indicated no issues, but one resident reported the elevator did not detect a cane. The allegation was substantiated based on observations and interviews.

The complaint alleged that the facility elevator was not in good operating condition, specifically that the elevator door crushed a person's hand because the sensor did not detect the object. The allegation was substantiated after investigation.

The visit was an unannounced complaint investigation conducted in response to multiple allegations received on 03/24/2022 regarding staff qualifications, quality of food, resident confinement, hydration, staffing adequacy, cleanliness, and assistance with oral hygiene.

The investigation included interviews with staff and residents, facility tour, and record reviews. All allegations were found to be unsubstantiated based on interviews, observations, and documentation. The facility was found to be adequately staffed, clean, and providing appropriate care and services.

The complaint investigation addressed nine allegations including staff qualifications, food quality, resident confinement, hydration, staffing levels, cleanliness, and oral hygiene assistance. All allegations were determined to be unsubstantiated due to lack of supporting evidence.

The visit was an unannounced complaint investigation conducted in response to multiple allegations received on 2022-01-26 regarding food quality, mail privacy, medication administration, billing practices, and meal scheduling at the facility.

The investigation included interviews with residents and staff, and a review of resident records. All allegations were found to be unsubstantiated based on the evidence gathered, including observations and interviews indicating no issues with food quality, mail privacy, medication administration, billing, or meal times.

The complaint investigation addressed nine allegations including serving inedible food, opening residents' mail, administering non-prescribed medication, charging for services not received, and not serving meals on schedule. After interviews and record reviews, all allegations were determined to be unsubstantiated due to lack of evidence.

The inspection was an unannounced complaint investigation visit conducted to determine the validity of allegations including staff not assisting a resident in a timely manner and facility equipment posing a hazard to residents.

The allegation that staff did not assist a resident in a timely manner was substantiated based on interviews with residents and staff. The allegation that facility equipment posed a hazard was unsubstantiated due to lack of evidence. A deficiency was cited related to failure to provide timely assistance to residents.

The complaint investigation was substantiated for the allegation that staff did not assist a resident in a timely manner, with six out of ten residents confirming delays of 30 minutes to an hour. The allegation that facility equipment posed a hazard was unsubstantiated.

The visit was an unannounced complaint investigation conducted to investigate allegations including staff retaliation against a resident, staff making false statements regarding a resident, and failure to assist a resident with obtaining medical care.

The investigation found no preponderance of evidence to substantiate the allegations. Staff denied retaliation and eviction threats, and the resident confirmed no eviction notice was received. Allegations of false statements about smoking and failure to assist with medical appointments were also unsubstantiated based on interviews and record reviews.

The complaint involved allegations that staff retaliated against a resident by attempting eviction, made false statements about the resident smoking in his/her room, and failed to assist the resident with medical appointments. After investigation including interviews with staff and residents and record review, all allegations were found unsubstantiated.

An unannounced complaint investigation was conducted following a complaint received on 2022-02-25 regarding residents' toileting needs not being met timely and residents not being treated with respect.

The investigation substantiated that residents experienced long wait times of 45 minutes to an hour for toileting assistance and that staff did not always treat residents with respect, including incidents of staff not knocking before entering rooms and speaking inappropriately to residents.

The complaint investigation was substantiated based on interviews with residents and staff. Six residents corroborated long wait times for toileting assistance, and five residents witnessed staff not treating residents with respect. The preponderance of evidence standard was met.

The inspection visit was conducted to investigate a complaint alleging that the facility elevator was in disrepair.

The investigation found that one of the two elevators near the dining area had stopped working but was reset by maintenance staff as instructed by the elevator company. No residents were trapped, and the elevator was operating properly at the time of the visit. The allegation was determined to be unsubstantiated due to lack of evidence.

The complaint alleged that the facility elevator was in disrepair. The allegation was unsubstantiated after investigation, including interviews with residents and staff, elevator testing, and review of maintenance documentation.

The inspection was an unannounced complaint investigation visit conducted to investigate allegations received on 12/07/2021 regarding inadequate food service and improper medication administration at the facility.

The investigation found no substantiated evidence to support the allegations. The food service was observed to be adequate with positive feedback from residents and staff, and medication administration was reviewed with no issues found. Therefore, the allegations were unsubstantiated.

The complaint alleged that staff failed to provide adequate food service and failed to administer medication as instructed by a physician. After interviews with residents and staff, medication reviews, and facility tour, the allegations were found unsubstantiated due to lack of evidence.

Licensing Program Analyst Vasallo conducted an annual required visit to evaluate the facility, including infection control, physical plant, medications, food supply, and staff files.

The facility was found to be in compliance with no deficiencies observed. Resident rooms, safety features, food supply, and COVID-19 procedures met regulatory requirements.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 09/28/2021 regarding resident safety, staff conduct, and COVID-19 testing practices at the facility.

The investigation found the allegations that a resident went missing and staff harassed residents to be unsubstantiated. However, the allegations that the facility failed to provide residents with an accounting of their funds and did not notify residents of positive COVID-19 results were substantiated.

The complaint investigation was initiated due to allegations including a resident going missing, staff harassment of residents, failure to test residents after possible COVID exposures, failure to provide residents an accounting of their funds, and failure to notify residents of positive COVID results. The investigation concluded the first three allegations were unsubstantiated, while the last two were substantiated.

The inspection visit was conducted to investigate complaints alleging unqualified staff administering medication to residents and staff not administering residents' medication in a timely manner.

The investigation substantiated the allegation that unqualified staff administered medication due to multiple medication technicians calling off sick. However, the allegation regarding untimely medication administration was unsubstantiated based on interviews with residents and staff.

The complaint investigation was substantiated for unqualified staff administering medication but unsubstantiated for untimely medication administration. The preponderance of evidence standard was met for the first allegation but not for the second.

The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 09/08/2021 regarding staffing shortages, medication mismanagement, dietary inadequacies, food service issues, and facility cleanliness at San Dimas Retirement Center.

The investigation substantiated allegations that the facility is short staffed, residents are receiving medications and treatments late, dietary needs are not being met due to poor food quality and limited options, food is often served cold, and the facility is dirty with neglected carpet cleaning due to maintenance staff shortages. Two allegations regarding lack of activities and untrained staff administering medication were found unsubstantiated.

The complaint investigation was substantiated for allegations of short staffing, medication mismanagement, late administration of medications, unmet dietary needs, inadequate food services, and facility cleanliness issues. Allegations that residents were not provided activities and that untrained staff administered medications were unsubstantiated.

The inspection was an unannounced complaint investigation visit conducted to investigate an allegation that the facility is maintained in disrepair, specifically regarding Resident #1's air conditioning unit.

The investigation included interviews with residents and staff and a facility tour. The allegation that the air conditioning unit was not installed properly was found to be unsubstantiated based on the evidence and interviews.

The complaint was unsubstantiated as there was no preponderance of evidence to prove the alleged violation occurred. Staff and residents denied the allegation, and the air conditioning unit was found to be properly installed and operating.

The inspection was an unannounced complaint investigation visit conducted to investigate allegations that staff did not assist residents with medications as needed.

The investigation found that 5 out of 11 residents interviewed reported missed or late medications, and 7 out of 10 staff reported the facility was short staffed, leading to delayed medication administration and missed treatments. The allegation was substantiated based on interviews and records reviewed.

The complaint was substantiated. The investigation included interviews with residents and staff, review of rosters and schedules, and facility tour. Staff admitted medication delays and missed treatments due to staffing shortages. The preponderance of evidence standard was met.

The inspection was an unannounced complaint investigation visit triggered by allegations including insufficient staffing to meet residents' needs, resident falls, intercom disrepair, unmet bathing needs, and lack of communication by the administrator with resident representatives.

The investigation substantiated the allegation of insufficient staffing causing delays in resident care, including medication administration and response to call lights. Other allegations regarding resident falls, intercom disrepair, bathing needs, and administrator communication were found unsubstantiated based on interviews and observations.

The complaint investigation was substantiated for insufficient staffing to meet residents' needs. 12 out of 16 residents and 8 out of 16 staff reported short staffing causing delays in medication administration, call light response, and other care. Other allegations including unwitnessed resident fall, intercom disrepair, unmet bathing needs, and lack of administrator communication were unsubstantiated.

The inspection visit was an unannounced complaint investigation triggered by a complaint received on 2021-06-28 regarding the quality of food served to residents.

The investigation found that residents and staff confirmed the food quality was poor, describing it as too salty, tough, not well cooked, and watered down drinks. Staff and residents expressed concerns about unhealthy food choices and cost-cutting measures affecting food quality. The allegation was substantiated.

The complaint was substantiated based on interviews with 11 residents and 8 staff, observations of the facility including kitchen and food storage, and review of food quality concerns. The complaint control number is 28-AS-20210628091908.

Licensing Program Analyst Vasallo conducted a case management visit to issue deficiencies related to the facility's failure to report a COVID-19 positive case that occurred on 04/08/2021.

The facility had a COVID-19 positive case on 04/08/2021 which was not reported to the licensing agency as required. Deficiencies were issued for failure to meet reporting requirements.

The inspection was an unannounced complaint investigation visit conducted to investigate allegations received on 06/07/2021 regarding staff not preventing inappropriate behaviors between residents, inadequate food service, and inadequate linens for residents.

The investigation included interviews with 7 staff and 11 residents, a facility tour, and review of menus and rosters. All allegations were found to be unsubstantiated based on interviews, observations, and lack of evidence.

The complaint included allegations that staff did not prevent inappropriate behaviors between residents, did not provide adequate food service, and did not provide adequate linens. After investigation, all allegations were unsubstantiated due to insufficient evidence or contradictory reports.

The visit was an unannounced complaint investigation conducted in response to a complaint received on 2021-03-29 regarding allegations that staff did not issue a refund and staff took residents' personal items.

The investigation found no preponderance of evidence to substantiate the allegations. The refund issue was explained by legal restrictions on cashing SSI checks after a resident's death, and the facility mailed a refund check. Regarding personal items, residents and staff confirmed no items were missing, and remaining property was made available for family pickup.

The complaint involved allegations that staff did not issue a refund and took residents' personal items. The investigation included interviews with residents, staff, the administrator, and the Power of Attorney for Resident #1. The allegations were determined to be unsubstantiated.

The visit was an unannounced complaint investigation conducted to investigate allegations that staff did not administer residents' medication as instructed by a physician, residents' care needs were not met resulting in a foot infection, staff did not schedule a resident's podiatrist appointment, and staff falsified documents.

The investigation substantiated the allegation that residents in the dementia unit were not receiving medications as prescribed, including missing medications and improper medication crushing and administration. The allegations regarding unmet care needs resulting in a foot infection, failure to schedule a podiatrist appointment, and falsification of documents were found to be unsubstantiated due to lack of evidence.

The complaint investigation was substantiated for medication administration issues in the dementia unit, including missed medications and improper crushing and administration methods. Other allegations regarding foot infection, podiatrist appointment scheduling, and document falsification were unsubstantiated.

The inspection was an unannounced complaint investigation conducted in response to multiple allegations received on 2021-01-21 regarding staff not attending to residents' calls, untimely assistance to see the facility doctor, inadequate bathing assistance, unsanitary food service practices, improper medication assistance, and a resident burn incident.

The investigation included interviews with staff and residents and virtual tours. All allegations were found to be unsubstantiated due to lack of evidence or contradictory statements from staff and residents. The call system and hot water temperature were tested and found to be functioning properly.

The complaint investigation was triggered by allegations including staff not attending to resident calls, untimely assistance to see the doctor, inadequate bathing assistance, unsanitary food service, improper medication assistance, and a resident burn. All allegations were unsubstantiated after investigation.

The inspection was conducted as a complaint investigation following allegations that a resident sustained multiple pressure injuries, the resident's bed was in disrepair, and the resident was not receiving proper nutrition at the facility.

The investigation found that the resident had only one stage II pressure wound being treated by home health, the bed was functioning properly, and the resident was receiving adequate nutrition. There was insufficient evidence to substantiate the allegations, and all were determined to be unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included multiple pressure injuries, bed disrepair, and improper nutrition. Interviews with facility staff, the resident, and home health nurse, as well as review of care plans and documentation, did not support the allegations.

An unannounced case management visit was conducted telephonically due to COVID-19 to investigate the death of Resident #1 (R1) which occurred on 04/01/2021.

The investigation is ongoing as additional information and documentation related to Resident #1's death were requested and have not yet been received.

Investigation was initiated due to the death of Resident #1. The investigation remains open pending receipt of requested documents.

The inspection was conducted as an unannounced complaint investigation following a complaint alleging a questionable death at the facility.

The investigation found that the allegation of a questionable death was unfounded; the resident in question was confirmed to be safe and currently living in the facility. The complaint was dismissed as false and without reasonable basis.

The complaint alleged a questionable death of Resident #1 at the facility. The investigation included telephone interviews with staff and residents, a virtual tour, and review of death reports. It was confirmed that Resident #1 was alive and well, and the complaint was found to be unfounded.

The inspection was conducted as an unannounced complaint investigation following a complaint received on 12/29/2020 alleging that staff refused to maintain a comfortable temperature for a resident.

The investigation, conducted telephonically due to COVID-19 mitigation measures, found that the resident had an issue with the original room being cold and near a smoking area. Staff offered to move the resident, who agreed and is now comfortable in the new room. Both staff and resident denied the allegation that staff refused to maintain a comfortable temperature. The allegation was unsubstantiated due to lack of preponderance of evidence.

The complaint was unsubstantiated. Although the allegation may have happened or is valid, there was not a preponderance of evidence to prove the alleged violation did or did not occur.

The inspection was an unannounced complaint investigation triggered by an allegation that staff mishandled a resident's medication.

The investigation confirmed that on 11/8/20, staff mistakenly presented Resident #1 with a pill that did not belong to them due to similar resident names. The resident did not ingest the pill, and corrective actions were planned including staff training and separating medications for residents with similar names.

The complaint was substantiated based on interviews and evidence. The allegation involved staff mishandling a resident's medication, which was confirmed during the investigation.

The inspection was an unannounced complaint investigation triggered by an allegation that staff mishandled a resident's medication.

The investigation confirmed that on 11/8/20, a staff member mistakenly handed medication to the wrong resident due to similar resident names. The facility took corrective action by separating medications for residents with similar names. The allegation was substantiated based on interviews and documentation.

The complaint was substantiated. The investigation involved interviews with staff and the resident, review of medication administration records, and confirmed a medication error occurred due to confusion between residents with similar names.