197607655-6-9-2021-28-AS-FFIS-C8KR85-20211108114719

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607655
Report Date: 06/09/2021
Date Signed: 06/09/2021 03:39:52 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
06/02/2021 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20210602092415

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: 108	DATE:	06/09/2021
		UNANNOUNCED	TIME BEGAN:	11:35 AM
MET WITH:	Virginia Garcia - Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Physical altercation between two residents due to lack of supervision

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst(s) Mary Flores and Nina Galarza conducted an unannounced compliant investigation due to the above allegations. LPA(s) met with Virginia Garcia facility's administrator and explained the reason of the visit.

The investigation consisited of the following: LPA(s) interviewed administrator, Resident #1(R1), were unable to interview resident #2(R2) as R2 is currently at the hospital, reviewed R1 and R2 facility's file and requested copies of Physician's report, Individual Services Plan, Identification and Emergency Information for R1 and R2, Incident Report, Police Report, and discharge papers for R1. In addition LPA(s) interviewed resident #3(R3),#4(R4),#5(R5),#6(R6),#7(R7),#8(R8),#9(R9),#10(R10) and staff #1(S1),#2(S2),#3(S3),#4(S4),#5(S5),#6(S6),#7(S7).

The investigation revealed the following: Regarding allegation; Physical altercation between two residents due to lack of supervision. It is alleged R#2 ran over R1's feet with his wheelchair and punched R1 in the face because R1 would not move out of the way to let R2 pass. (CONTINUED 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: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

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

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 28-AS-20210602092415

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: 06/09/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Interviews conducted with 1 out of 11 residents stated there is staff present in the common areas, 1 out of 11 residents stated there is not enough staff at the facility and 9 out of 11 residents were not able to answer questions due to cognitive skills. Interviews with staff; 3 out of 7 staff interview stated that there is a floor supervisor who assist the caregivers throughout the shift. 5 out of 7 staff stated that S7 was walking by when the incident happened and attempted to redirect R2. Based on interviews the incident took place near an elevator in the second floor of the facility were R2 was sitting down on chair available in hallway, S7 was walking by when incident took place and attempted to de-escalated the situation. S2, S3, and S5 who were down the hall heard and/or observed the incident and walked over to assist S7. S6 stated to be called on radio to assist with incident, S6 moved from the first floor to the second floor and observed the incident upon arriving. Documents reviewed revealed R2 was admitted to the facility on 4/23/21. R2's Individual Service Plan - Socialization states R2 "may exhibit stress or agitation transitioning to a new environment." R1 Hospital discharge document indicates assault, jaw pain. Impression: No acute traumatic injury noted. On 5/30/21 Pasadena Police department was contacted by facility, administrator stated officers did not press chargers per family member request or assisted with 5150 as R1 has a diagnosis of dementia. Pasadena police department business card was provided with police report # 21005733. On 5/30/21 facility submitted a Report of Suspected Dependent Adult/Elderly Abuse (SOC 341) via phone call. On 5/31/21 Facility mail incident report to Community Care Licensing (CCLD). On 6/8/12 family member stated to have taken R1 to the hospital to be check after the incident and there were no bruises or injuries visible.

Based on LPA's documents reviewed and interviews 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 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: 06/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2