197607655-8-7-2020-28-AS-MVAO-BTJPWF-20200917114039

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607655
Report Date: 08/07/2020
Date Signed: 08/07/2020 03:50:36 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/09/2020 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20200709140718

FACILITY NAME:	JASMIN TERRACE AT EL MOLINO		FACILITY NUMBER:	197607655
ADMINISTRATOR:	VIRGINIA GARCIA		FACILITY TYPE:	740
ADDRESS:	245 S. EL MOLINO AVE.		TELEPHONE:	(626) 578-0460
CITY:	PASADENA	STATE: CA	ZIP CODE:	91101
CAPACITY:	206	CENSUS: 102	DATE:	08/07/2020
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Virginia Garcia - Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not provide resident with comfortable mattress.

INVESTIGATION FINDINGS:

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Licensing Program Analyst LPA Mary Flores conducted a subsequent complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Virginia Garcia, the facility administrator.

The investigation consisted of the following: LPA Flores on 7/13/20 conducted telephone interviews with the administrator, assistant administrator, a video call which consisted of a review of physical plant; random tour of the following rooms #101, 103, 108, 117, 125, 201, 205, 219, 223, and 237. The LPA also requested copies of Physician's bed rail request for residents #1, 2, 3, 4, 5, and 6 (R1,R2,R3,R4,R5,R6), and interview R#10’s family member. On 7/14/20, LPA conducted video call interviews with 9 residents, Resident #1,2,3,4,5,6,7,8,9 (R1,R2,R3,R4,R5,R6,R7,R8,R9) and toured room #202. The LPA also requested copies of Physician’s Report for R1,R2,R3,R4,R5,R6,R7,R8,R9,R10 and Physician's bed rail request for R5. On 7/17/20, 7/24/20, and 7/31/20 LPA received copies of the requested documents via email.On 8/7/20, LPA toured room #125 and #201. (Continued on 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20200709140718

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: JASMIN TERRACE AT EL MOLINO	FACILITY NUMBER: 197607655
	VISIT DATE: 08/07/2020

NARRATIVE

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The investigation revealed the following: Regarding allegation; staff did not provide a comfortable mattress; it is alleged that resident couldn’t sleep and when he was trying to make himself comfortable, he fell off the bed. Interviews with residents revealed; 7 out of 9 residents interviewed stated not to have complaints regarding their mattress, to be sleeping well in mattress, believe mattress is comfortable, and/or do not feel pain due to sleeping in mattress. R2 stated to have trip getting up from the bed but not fallen out of the bed. 2 out of 10 residents were unable to answer LPA's questions due to their cognitive skills or dementia. One (1) resident required translation. Therefore LPA interviewed family member, who stated to not have concerns regarding R10’s furniture, mattress, or bedding and to be happy with R10 at facility, as R10 has said to "like it very much". During the tour of the facility; Assistant administrator stated “family requested for bed to be change from a twin to a full size. Order was place on 7/9/20 and this bed will be change to a full size bed.” in room #201. LPA toured 11 rooms randomly and observed mattresses with padding, mattress covers, bottom and top sheets, blanket, cover, and pillows available in each room. Interview with administrator revealed resident’s mattresses are change minimum every 6 months or as requested due to incontinence of residents. Facility provides residents with furniture unless the resident or representative provides their own furniture. Assistant administrator stated that staff check mattresses every month to see if there is need to exchange mattress due to incontinence and mattresses may be change as needed. On 7/14/20, Assistant Administrator stated they had change R2's bed from a twin to a full and LPA observed the bed over the video call, mattress was in good condition, and bed had all required bedding. On 8/7/20 LPA observed mattresses in rooms #125 and 201 as during the virtual tour administrator said those mattresses will be change. LPA observed the mattresses in good condition. Based on interviews conducted with residents and staff, observations, and documents review there was not enough supporting evidence to concur with the allegation.
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.

A telephonic exit interview was conducted with Virginia Garcia Assistant Administrator, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2020

LIC9099 (FAS) - (06/04)

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