197607655-7-9-2021-28-AS-MVAO-C5ANJX-20210726103103

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607655
Report Date: 07/09/2021
Date Signed: 07/09/2021 05:14:40 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
12/07/2020 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20201207161142

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: 109	DATE:	07/09/2021
		UNANNOUNCED	TIME BEGAN:	11:56 AM
MET WITH:	Virginia Garcia - Administrator		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Residents are not assisted with incontinence care
Licensee did not ensure residents receive adequate daily food intake.
Licensee did not provide adequate hygiene supplies

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s) (LPAs) Mary Flores and Luis Mora conducted an unannounced complaint investigation regarding the above allegations.

The investigation consisted of the following: On 12/8/20 LPA Flores conducted telephone interviews with the assistant administrator, wellness director, and a video call which consisted of a review of food supply, incotinence care, and hygiene supplies. The LPA also requested copies of the following documents for residents #1,#2,#3,#4,#5,#6,#7,#8,#9 (R1,R2,R3,R4,R5,R6,R7,R8,R9) to be emailed Physician’s Report, Needs and Service Plan, MARS, Admission’s agreement, Caregiver, Hospice, or Nurse notes, food receipts for 1 month, Hygiene, and incontinence care supplies invoices and receipts for the last 3 months, Caregiver’s daily schedule and assignments for the last 3 weeks, Caregivers list for each shift with phone numbers. On 7/9/21 LPA Mora conducted a tour of the kitchen, storage bin, storage rooms #210 and #245 and storage A and storage B. LPAs conducted interviews with R1,R2,R4,R5,R6,R8, resident #9(R9), #10(R10), #11(R11), #12(R12), and staff #1(S1), #2(S2), #3(S3), #4(S4), #5(S5), #6(S6),#7(S7). LPA requested staff/resident roster, appraissal needs and care plan, physician's report for all residents, facility menu's for the month of June, caregivers assigment schedule for 7/2/21 - 7/9/21 (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: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

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-20201207161142

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: 07/09/2021

NARRATIVE

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Invoices for food produce and hygiene supplies delivered for the month of June.

The investigation revealed the following: Regarding allegations: Residents are not assisted with incontinence care. It is alleged that facility does not have sufficient diapers or wipes and that due to the diaper and wipe issue, residents are getting "skin problems." During the facility's tour LPAs observed room #210 which contained personal protective equipment (PPE) and boxes of diapers, room #245, storage A, and B, and outside storage containing boxes of diapers in size S, M, L, XL and boxes of wipes were observed in storage A. During interviews with residents 5 out of 10 residents stated to not need assistance with using the toilet and/or do not wear a diaper. 2 out of 10 residents are assisted with going to the toilet and/or with diaper. 3 out of 10 residents were unable to be interview due to cognitive skills. During interviews with 4 staff out of 7 staff stated to assist residents with incontinence care every 2 hours or as needed and to have sufficient diapers and wipes to assist the residents. 1 staff out of 7 staff stated that when staff run out of diapers there are only small diapers and use small diapers with all residents. 2 out of 7 were not familiar with incontinence care. Administrator stated facility maintains 2 months worth of supplies. Documents reviewed showed that 8 out of 12 residents need assistance with toileting care and 4 out of 12 do not need assistance for toileting.
Based on LPA's observation, interviews, and document reviews conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found Unsubstantiated.

Regarding allegations: Licensee did not ensure residents receive adequate daily food intake. It is alleged staff can not take the time needed to sit and spoon feed residents their entire meals. During facility's tour LPA observed sufficient food for 2 days of perishables and 7 days of non-perishables; such as vegetables, fruits, dry goods, meats. LPAs reviewed 4 facility's menus for the month of June which have a variety of meals for each week and a total of 9 invoices for food produce for the period of 6/21/21 to 7/7/21. During interviews with residents 5 out of 10 residents stated to eat independently. 5 out of 10 residents were unable to be interview due to cognitive skills. During interviews with staff, 4 out of 7 staff stated staff are able to assist residents with meals and residents eat as much as they need, 2 out of 7 staff stated to see at least 50% of the food had been eating from residents that eat puree meals or need assistance eating. 1 out 7 staff stated not to have sufficient time to assist residents with feeding. Documents reviewed revealed 8 out of 12 residents do not need assistance with feeding and 4 out of 12 need assistance with feeding.
Based on LPA's observation, interviews, documents reviews conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found Unsubstantiated

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20201207161142

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: 07/09/2021

NARRATIVE

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Regarding allegations: Licensee did not provide adequate hygiene supplies. It is alleged that residents that need large size diapers are wearing small size diapers due to no diaper or wipes being available at the facility. During the facility's tour LPAs observed room #210 which contained personal protective equipment (PPE) and boxes of diapers, room #245, storage A, and B, and outside storage containing boxes of diapers in size S, M, L, XL and boxes of wipes were observed in storage A. LPAs reviewed a total of 8 invoices for hygiene supplies orders between 5/6/21 and 7/1/21. During interviews with 4 staff out of 7 staff stated to assist residents with incontinence care every 2 hours or as needed and to have sufficient diapers and wipes to assist the residents and to have different sizes available. 1 staff out of 7 staff stated that when staff run out of diapers there are only small diapers and use small diapers with all residents. 2 out of 7 were not familiar with incontinence care. Administrator stated facility maintains 2 months worth of supplies. Documents reviewed showed that 8 out of 12 residents need assistance with toileting care and 4 out of 12 do not need assistance for toileting.

Based on LPA's observation, interviews, and document reviews conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found Unsubstantiated.

Exit interview was conducted with Virginia Garcia administrator and a copy of the 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: 07/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2021

LIC9099 (FAS) - (06/04)

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