197607655-7-14-2021-28-AS-LHIS-C74SND-20210922140123

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607655
Report Date: 07/14/2021
Date Signed: 07/14/2021 05:17:09 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
04/21/2021 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210421112431

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: 112	DATE:	07/14/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Malou Bernando,		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility is understaffed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to deliver the findings for the allegations listed above. LPA met with Lori Lackey, the Assistant Administrator and explained the purpose of the visit. Administrator, Virginia Garcia, arrived shortly thereafter.

The investigation consisted of the following:

On 4/27/21, LPA Chan conducted the initial visit telephonically and interviewed the Assistant Administrator. LPA also requested copies of the LIC500 Personnel Report which includes phone numbers and Resident roster. During the onsite visit today, LPA toured the facility and conducted interviews with the Administrator, 9 Staff and 12 Residents.

(Continue on LIC9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021

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-20210421112431

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: 07/14/2021

NARRATIVE

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The investigation revealed the following for allegation – Facility is understaffed. The Administrator stated that they have adequate staffing at this time. According to the Administrator and LIC500 Personnel Report, there are 27 Caregivers and 12 cleaning staff which consist of the housekeepers, janitors, and laundry. The staffing mentioned have rotated schedules. Per Administrator, the caregivers are assigned to 15 residents a day and the level of care are balanced so that not one staff carries a heavy load. LPA interviewed a total of 12 Staff of different positions and 12 residents. While the majority of the residents feel there are sufficient staffing, 2 residents cannot determine if there is a shortage of staff but have heard they are hiring more. 6 out of 12 Staff interviewed do not feel there is sufficient staffing in either the caregiver or housekeeper department. Some staff interviewed stated they are assigned between 13-18 residents per shift. Their duties include doing room checks every 2 hours, brushing their teeth, dressing, changing diapers, showering, toileting, feeding, transferring to and from wheelchair for a few of the residents. They indicated that sometimes they may have a backup staff but not always. When they are unable to find coverage, they have staff cover additional residents. Some staff have indicated they feel stressed at times depending on the needs of the residents on that given day. In the housekeeping department, 2 of the staff indicated they are assigned to as many as 36 rooms to clean daily and may fill in for other cleaning duties as well. Per Administrative staff, they are in the process of hiring more staff at the facility. In the meantime, staff are working extra hours to cover another shift when someone calls out or until they hire new staff.

Based on interview conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), is being cited on the attached LIC 9099D.

An exit interview was conducted. The Plan of Correction was reviewed and developed with the Administrator, Virginia Garcia. A copy of this report and appeal rights were left with Administrator whose signature on this form confirm receipt of these documents.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20210421112431

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/14/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/21/2021 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements-General: a) Facility personnel shall at all times be sufficient in numbers,...In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care .... for the provision of adequate services. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The licensee shall review the amount of work in each department to determine if more staff are needed. In addition, the licensee shall submit a staffing plan by POC due date 7/21/21. LPA also requested to provide an updated LIC500 when staff are hired.
	8 9 10 11 12 13 14	Based on interviews and documents reviewed, licensee did not ensure there is sufficient staffing as 1 caregiver may be assigned between 13- 18 residents and 1 housekeeper may be cleaning up to 36 rooms in a day, which poses a potential Health, Safety, or Personal Rights risk for persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2021

LIC9099 (FAS) - (06/04)

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