197607655-5-28-2021-28-AS-MVAO-C49QTV-20210623122747

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607655
Report Date: 05/28/2021
Date Signed: 05/28/2021 05:11:41 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
12/02/2020 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20201202104422

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: 106	DATE:	05/28/2021
		UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Lori Lackey - Assistant Administrator		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Facility did not follow resident's care plan.
Staff are not meeting showering needs of resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s) (LPAs) Mary Flores and Luis Mora conducted a complaint investigation visit regarding the above allegation(s). LPAs met with Lori Lackey assistant administrator and explained the reason for the visit. Virginia Garcia administrator arrived 30 minutes later.

The investigation consisted of the following: On 12/8/20 LPA Flores conducted telephone interviews with the assistant administrator, a video call which consisted of a review of hygiene supplies. The LPA also requested copies of staff/resident's roster, caregiver’s list, caregiver’s daily schedule, caregiver’s duties, resident’s chart or schedule for daily/weekly care, the following documents for residents #1,#2,#3,#4,#5,#6,#7,#8,#9 (R1,R2,R3,R4,R5,R6,R7,R8,R9), Physician’s Report, Needs and Service Plan, MARS, Admission’s agreement, Caregiver, Hospice, or Nurse Notes to be emailed. On 5/28/21 LPAs conducted a tour of the facility which consisted of the kitchen, dinning rooms, common areas, and rooms #105,237,244,245, 251,217, 216, 214, 204, 201, nterviewed residents #1,(R1),#2(R2),#3(R3),#4(R4),#5(R5),#6(R6),#7(R7),#8(R8),#9(R9),#10(R10), staff #1(S1),#2(S2),#3(S3),#4(S4),#5(S5),#6(S6),#7(S7),#8(S8), and requested staff/resident roster, residents' needs and care appraisal, physician's report, caregivers asssigment shift for each shift, and shower list.
(CONTINUED ON LIC 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: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

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-20201202104422

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: 05/28/2021

NARRATIVE

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The investigation revealed the following: Regarding allegation: Facility did not follow resident's care plan. It is alleged family member and administration staff had a care plan meeting and it was agreed upon that resident would be showered every other day. During interviews with 2 out of 10 residents stated to receive assistance with their daily living, 5 out of 10 stated to not required assistance with daily living, and 3 out of 10 residents were not able to respond to interview due to cognitive or verbal skills. Interviews with 4 out of 8 staff stated that there is not sufficient caregivers at the facility, however the caregivers prioritize care for the residents incontinence care needs, meals, and showers are given to the residents every other day. 2 out of 8 staff are not familiar with residents needs and care and 2 out of 8 staff stated staff provided assistance to caregivers in order to provide care to residents and meet the resident care and needs plan. During residents document's review it was noted that 7 out of 10 residents need assistance with daily assistance living, such as showers, feeding, and/or toileting needs which were noted in resident care plan reviewed by the LPA(s).

Based on interviews and resident's documents reviewed the preponderance of evidence standard has been met, therefore the above allegation is UNSUBSTANTIATED.

Regarding allegation: Staff are not meeting showering needs of resident. It is alleged resident informed family member, resident has not been showered in over a week. During interviews with 2 out of 10 residents stated to receive assistance with their daily living, 5 out of 10 stated to not required assistance with daily living, and 3 out of 10 residents were not able to respond to interview due to cognitive or verbal skills. Interviews with 4 out of 8 staff stated that there is not sufficient caregivers at the facility, however the caregivers prioritize care for the residents incontinence care needs, meals, and showers are given to the residents every other day. 2 out of 8 staff are not familiar with residents needs and care and 2 out of 8 staff stated staff provided assistance to caregivers in order to provide care to residents and meet the resident care and needs plan. During residents document's review it was noted that 6 out of 10 residents need assistance with showers and it was noted on residents care plan reviewed by the LPA(s).

Based on interviews and resident's documents reviewed the preponderance of evidence standard has been met, therefore the above allegation is UNSUBSTANTIATED.

Exit interview was conducted with Lori Lackey assistant administrator and a copy of this report was provided.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021

LIC9099 (FAS) - (06/04)

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