Bayshire San Dimas

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not ensure alarmed exit doors work properly at all times Due to lack of supervision, resident eloped

This report today 10/10/25 supercedes the report dated 08/07/25 in which LPA inadvertently combined findings on the report. However the findings remain the same. 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 unthe state’s words, verbatim · CDSS document, Oct 10, 2025 · control 28-AS-20241119083111

Allegation investigated: Licensee does not ensure that facility is kept in good repair.

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. Substantiatedthe state’s words, verbatim · CDSS document, Sep 30, 2025 · control 28-AS-20250923141425

Allegation investigated: Facility staff are not properly turning resident resulting in pressure injury. Facility staff are leaving resident in bed for extended periods of time.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit to investigate above allegations. LPA discussed the purpose of the visit with Health & Wellness Director Laura Garcia. The investigation consisted of: A physical plant inspection of the Memory Care Unit & AL common areas and R1's room was conducted. An interview with resident (R1) was attempted. Five (5) residents and 7 staff, and SCAN Nurse Practioner were interviewed. Review/copies of R1's file documents was completed [Physician's Report, Service Plan, Admission Record, Resident Assessment, SCAN Home health order [8/20/25], SCAN Provider Assessment, Angel Hospice records, Plan of Operation, resident roster, and staff rosters were obtained. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 29, 2025 · control 28-AS-20250925100212

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: 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

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 inspthe state’s words, verbatim · CDSS document, Aug 7, 2025 · control 28-AS-20241119083111

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not ensure that sharp objects are inaccessible to residents in care.

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Laura Sanchez HSD (Health Services Director) who assisted with the visit. LPA explained the purpose of today’s visit. During today's visit, LPA obtained a copy of the staff and resident rosters, reviewed 7 residents files, interviewed Health Services Director (HSD), Facility Manager, Human Resources Director (HRD), Staff #1 - Staff #2 (S#1 - S#2), and Resident#1 - Resident#7 (R#1 - R#7). LPA also toured the facility including Memory Care Unit with the assistance of the HSD. Continue 9099C Substantiatedthe state’s words, verbatim · CDSS document, Feb 4, 2025 · control 28-AS-20250130173505

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility did not update physicians reports for residents with a change in condition.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced complaint investigation visit for the above-mentioned allegation. LPA met with Nadia Batista, HR Director and explained the purpose of the visit. Shortly after, Administrator Chad Coleman arrived and assisted LPA with the investigation. The investigation consisted of the following: LPA conducted a tour of the physical plant, interviewed Staff #1 (S1) - Staff #5 (S5) and Resident #1 (R1) – Resident #6 (R6). LPA reviewed and obtained copies of the Resident & Staff Rosters, Random Memory Care and Assisted Living residents - Resident #1 (R1) - Resident #6 (R6) files such as: Identification and Emergency Information (Face sheet), Appraisal/Needs and Services plans and Physicians’ reports. The investigation revealed the following: In regards to the allegation: “Facility did not update physicians reports for residents with a change in condition.” It is alleged that the residents’ physicians’ reports are not updated timelythe state’s words, verbatim · CDSS document, Jul 30, 2024 · control 28-AS-20240725121434

Allegation investigated: . Hazardous chemicals are left accessible to residents. 2. Staff not monitoring resident with sharp objects. 3. Staff left resident unattended. 4. Staff interfere with family council meetings. 5. Staff did not follow up on family council meeting concerns in a timely manner.

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint visit for the above allegations. LPA met with Lisa Gomez and explained the reason for the visit. The investigation consisted of the following: On 5/28/24, LPA Chan conducted the initial visit to gather documents and interviewed the facility manager, 5 staff and 5 residents. During the visit today, LPA interview a staff and reviewed personnel files. The investigation revealed the following: For allegations – “Hazardous chemicals are left accessible to residents” and “Staff not monitoring residents with sharp objects”. LPA toured the assisted living and memory care unit and interviewed staff and residents. LPA did not see any chemicals or sharp objects left accessible to residents. The cleaning solutions were locked in the cleaning carts or the storage room. Per staff, scissors are put away after usage. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 18, 2024 · control 28-AS-20240523135252

Allegation investigated: Facility did not update Needs and Services Plans for residents Facility did not update physicians reports for residents with a change in condition

Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced complaint investigation visit for the allegation(s) above. LPA met with Facility Manager Lisa Gomez and the purpose of the visit was discussed. LPA conducted the following on todays visit: Toured the physical plant, Interviewed staff #1-#5 (S1-S5) and Residents #1-#5 (R1-R5). LPA reviewed and collected the needs and services plans and physicians reports for R1-R5. LPA also collected a copy of the staff and resident roster. The investigation revealed the following: In regards to the allegaiton "Facility did not update Needs and Services Plans for residents" it is alleged that the needs and services plans for residents on file are outdated and do not reflect the residents actual care needs. (5) of (5) Staff interviewed denied the allegation... Continued on LIC 9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 16, 2024 · control 28-AS-20240710093533

Allegation investigated: Staff are preventing resident from receiving telephone calls.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced initial complaint visit to investigate the above allegation. LPA met with Lisa Gomez, General Manager and explained the purpose of the visit. During today’s visit LPA toured the facility’s common areas, lobby, reception area, obtained resident & staff rosters and Staff #2 (S2)'s timecard. LPA interviewed Staff #1 (S1) – Staff #5 (S5), Resident #1 (R1) – Resident #6 (R6). In regards to the allegation: “Staff are preventing resident from receiving telephone calls.” It is alleged that facility is never opened at 8am, front door is locked until 9am and calls were unanswered. (5) out of (5) interviewed staff denied the allegation. Interviewed staff stated that they are aware of the residents personal rights to have reasonable access to telephones, to both make and receive confidential calls. However, staff stated that residents in the Assisted Living unit have their own cell phones and do not have land lines set up in ththe state’s words, verbatim · CDSS document, Jul 2, 2024 · control 28-AS-20240625124331

Allegation investigated: Air conditioner is in disrepair

Licensing Program Analyst (LPA) Jose Villalobos conducted an initial unannounced complaint investigation visit for the allegation listed above. LPA met with Manager Lisa Gomez and the purpose of the visit was discussed. LPA's visit consisted of the following: a tour of the phyical plant which included the common rooms and memory care unit, LPA inspected room #'s 161, 165, 166, 170, 180, 181, and 186 which are all part of the memory care unit, LPA interviewed staff #1-6 (S1-S6) and residents #2-5 (R2-R5), Resident #1 (R1) is not available for interview. LPA collected maintenance notes fro the month of June 2024, LPA collected documents from R1's file as well as a copy of the staff and resident roster. The investigation revealed the following: Continued on LIC 9099-C Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 20, 2024 · control 28-AS-20240612155319

Allegation investigated: Staff are not meeting residents' dietary needs. Staff do not provide adequate amount of food to residents.

Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced initial complaint visit regarding the above allegations. LPA met with Nadia Batista, Human Reseources Director and explained the reason for the visit. At 1pm, Lisa Gomez, General Manager arrived and assisted LPA with the investigation. The investigation consisted of the following: LPA obtained copies of the staff and resident rosters, Weekly meal menu (May-June 2024), Always available menu, Residents' Dietary Communication list, and Dietitians information. During today’s visit, LPA along with Staff #3 (S3) toured the Kitchen, Dining room and inspected the food supplies. LPA interviewed Staff #1 (S1) – Staff #5 (S5) and Resident #1 (R1) – Resident #12 (R12). The investigation revealed the following: In regards to the allegation: “Staff are not meeting residents' dietary needs.”, it is alleged that staff is not following residents diets, that salt is added to no salt diet and food allergies are not being followed. Intthe state’s words, verbatim · CDSS document, Jun 18, 2024 · control 28-AS-20240610142018

Allegation investigated: Staff are violating residents’ personal rights by telling them not to file complaints with CCLD Staff did not treat resident with dignity and respect

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced initial complaint visit to determine the validity of the above-mentioned allegations. LPA met with Lisa Gomez (Manager) and explained the reason for the visit. The investigatiion consisted of the following: LPA Mora requested for copies of the staff and resident rosters, and interviewed the Manager, Staff 1 - Staff 9 (S1 - S9), and Resident 1 - Resident 8 (R1 - R8). LPA also toured rooms 152, 169, 183, 186, 219, 241, 319, and 341, staff office, kitchen and common area restrooms. LPA reviewed memory care caregivers' files and obtained a copy of caregivers' job duties. Regarding the allegation "staff are violating residents’ personal rights by telling them not to file complaints with CCLD", it is alleged that management is telling staff, residents, and family not to file complaints or concerns with state. (Continued to LIC 9099-C) Unsubstantiatedthe state’s words, verbatim · CDSS document, Jun 13, 2024 · control 28-AS-20240606082847

Allegation investigated: Staff does not ensure food service sanitation practices are followed

Licensing Program Analyst (LPA) Luis Mora conducted an unannounced subsequent complaint visit to determine the validity of the above-mentioned allegations. LPA met with Lisa Gomez (Manager) and explained the reason for the visit. The investigatiion consisted of the following: LPA Mora requested for copies of the staff and resident rosters, and interviewed the Manager, Staff 1 - Staff 9 (S1 - S9), and Resident 1 - Resident 8 (R1 - R8). LPA also toured rooms 152, 169, 183, 186, 219, 241, 319, and 341, staff office, kitchen and common area restrooms. LPA reviewed memory care caregivers' and kitchen staff files, and obtained a copy of caregivers' job duties. Regarding the allegation "staff does not ensure food service sanitation practices are followed", it is alleged that the caregivers in memory care do not have a food handlers card and they plate all the food in memory care, they do not use hair nets or have temperature logs. (Continued to LIC 9099-C) Substantiatedthe state’s words, verbatim · CDSS document, Jun 13, 2024 · control 28-AS-20240529144857

Allegation investigated: Staff do not give residents medication as prescribed

Licensing Program Analyst (LPA) Glenn Trueman conducted the initial complaint investigation for the allegation listed above. LPA arrived unannounced and met with Lisa Gomez, Manager. The purpose of the visit was discussed. During the visit today, LPA obtained copies of the staff roster and resident roster. Interviews with Lisa Gomez, Manager and Staff S1 were conducted from 10:15 AM to 10:45 AM. Interview was conducted telephonically with Staff S2 at 10:50 AM. Interviews were conducted with Residents R1-R6 from 11:10 AM to 11:55 AM. LPA toured the medication room and reviewed medication records for R1-R6. In regards to the allegation Staff do not give residents medication as prescribed, based on interviews conducted, medication review and information gathered it was revealed in review of medication for R1-R6 that all medication was given as prescribed and R1-R6 did not miss any doses. Review of pain medication showed that all doses were given as prescribed. Interviews with R1-R6 who althe state’s words, verbatim · CDSS document, Jun 4, 2024 · control 28-AS-20240531152939

Allegation investigated: Facility is in disrepair resulting in leaks. Staff does not ensure facility carpet is clean and sanitized.

Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced complaint investigation regarding the above allegations. LPA met with Manager, Lisa Gomez who assisted with the visit. Regarding the allegation that : Facility is in disrepair resulting in leaks. The investigation consisted of tour of facility, including memory care, interviews with Staff #1 - Staff #4, and Resident #1 - Resident #6. LPA did not observe any leaks during facility tour. Staff interviewed stated that there are no leaks in the facility. Staff indicated that if any leaks are reported or observed, maintenance staff will repair it right away. Residents interviewed did not corroborate the allegation. Six out of six residents stated that they have not observed any leaks in the facility. Regarding the allegation that : Staff does not ensure facility carpet is clean and sanitized. The investigation consisted of tour of facility, including memory care, and interviews with Staff #1 - Staff #4, and Resident #1 - Rthe state’s words, verbatim · CDSS document, May 30, 2024 · control 28-AS-20240521095500

Allegation investigated: Staff was under the influence while on shift Staff yelled at residents in care

On 5/30/2024 at 9:15 a.m., Licensing Program Analyst (LPA) Baptiste made an unannounced complaint visit to the facility to investigate the allegations listed above. LPA Baptiste met with the Manager, Lisa Gomez, and explained the purpose for the visit. During the visit today, LPA obtained a copy of staff roster and client roster. LPA Baptiste toured the facility with Plant Ops Director and reviewed facility files for the Manager and Staff #1(S1). LPA Baptiste also interviewed the Manager and a total of three (3) staff, whom shall be known as Staff #1 through Staff #3. LPA also interviewed a total of six (6) residents, whom shall be referred to as Resident#1 through Resident# 6. LPA attempted to interview Resident #7, but they declined to be interview. (Report continued on LIC9099-C...) Unsubstantiatedthe state’s words, verbatim · CDSS document, May 30, 2024 · control 28-AS-20240523091436

Allegation investigated: Licensee did not complete an admission agreement for resident.

Licensing Program Analyst (LPA) Galarza conducted an initial 10-day complaint investigation visit regarding the above allegation. LPA discussed the purpose of the visit with Manager Lisa Gomez. Administrator Chad Coleman was interviewed telephonically. The investigation consisted of: A physical plant tour of interior common areas and resident bedrooms was conducted.Staff (S1- S4), residents (R1- R8), and family (F1) Resident (R1 & R2's) file documents were reviewed. Copies of Residence and Care Agreement, Move In-Record, Physician's Report, Pre-placement Appraisals, Resident Care Evaluation Admission Appraisals, staff roster, and resident roster were obtained. ***See narrative summary on next page.*** Substantiatedthe state’s words, verbatim · CDSS document, May 30, 2024 · control 28-AS-20240524124243

Allegation investigated: Licensee does not ensure the facility has an administrator present a sufficient number of hours to adequately manage facility. Staff are preventing resident from receiving telephone calls.

Licensing Program Analyst (LPA) V. Maldonado made an unannounced initial complaint visit to the facility for the purpose of investigating the above mentioned allegations. LPA Maldonado met with Health Services Director, Heather O'Neel and explained the purpose of the visit. Executive Director, Chad Coleman arrived shortly after to assist with the visit. During today's visit, LPA Maldonado obtained a copy of the resident and staff roster, and obtained pertinent documents for Staff#1-2 (S1-S2). Interviews were also conducted with Staff#1-9 (S1-S9) and Residents#1-5 (R1-R5). The investigation revealed the following: (Report continued on LIC9099-C...) Substantiatedthe state’s words, verbatim · CDSS document, May 21, 2024 · control 28-AS-20240517121025

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility in disrepair Facility staff do not provide meals of the quality necessary Laundry room does not have adequate supplies Facility does not have a qualified administrator

***This is an amended report which supersedes the original report dated 04/16/24. The purpose of this report is to remove confidential information. The amendment to the report does not affect or change the findings on this complaint***. Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced complaint investigation visit regarding the above allegations. LPA Margaryan met with Health Services Director (HSD), Heather O'Neel who assisted with the visit. Purpose for the visit was explained. During today's visit, LPA Nune Margaryan obtained a copy of the resident and staff roster, copy of the facility menu, Personnel Records and Administrator Certificates for the facility Administrator Chad Coleman and Health Services Director (HSD), Heather O'Neel. LPA toured the facility including the kitchen, dining room, laundry rooms and randomly chosen residents rooms. Interviewes condacted with HSD Heather O'Neel , Staff #1 - Staff #5 (S#1 - S#5) and Resident #1 - Resident #7 .(R#1 -the state’s words, verbatim · CDSS document, Apr 16, 2024 · control 28-AS-20240411122938

Allegation investigated: Staff do ensure the facility's communication devices are properly operating.

Licensing Program Analyst (LPA) Nune Margaryan conducted an unannounced 10 day complaint visit to this facility. Upon arriving at the facility, LPA met with Heather O'Neel HSD (Health Services Director) who assisted with the visit. LPA explained the purpose of today’s visit. During today's visit, LPA obtained a copy of the staff and resident rosters, work note from Facility Operational Analyst / IT, interviewed Heather O'Neel - HSD, Staff #1 - Staff #5 (S#1 - S#5), Facility Operation Analyst / IT and Resident#1 - Resident#6 (R#1 - R#6). The Facility Operation Analyst / IT was intervewed over the phone. LPA also toured a random selection of resident rooms on each floor with the assistance of the HSD. Continue 9099C Unsubstantiatedthe state’s words, verbatim · CDSS document, Apr 11, 2024 · control 28-AS-20240403151615

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.