197607655-9-15-2021-28-AS-MVAO-CAMQ4Q-20220113105044

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607655
Report Date: 09/15/2021
Date Signed: 09/15/2021 04:50:59 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
09/09/2021 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20210909140854

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: 119	DATE:	09/15/2021
		UNANNOUNCED	TIME BEGAN:	01:19 PM
MET WITH:	Virginia Garcia - Administrator		TIME COMPLETED:	05:10 PM

ALLEGATION(S):

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Facility is not reporting documentation as required by a public agency

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA Flores met with Virginia Garcia and explained the reason for the visit.

The investigation consisted of the following: LPA Flores interviewed administrator and assistant administrator, requested a copy of staff and resident roster showing admissions for July and August 2021, copies of Assisting Living Form (ALW), COVID vaccination records, admission agreement for Resident #1(R1), #2(R2), #3(R3), #4(R4), #5(R5), emails to public agency and placing agency.

The investigation revealed the following: Regarding allegation; Facility is not reporting documentation as required by the department. It is alleged facility has failed to submit required documentation within 24 hours of admission for five out of eleven new residents. Interview with administrator revealed new admissions at the facility are process within 2 weeks, depending on the case manager or nursing facility processing the admission. ALW verification of approval may be in a different format. (CONTINUED LIC9099)

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: 09/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

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-20210909140854

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: 09/15/2021

NARRATIVE

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On 4/22/21 an office meeting was held with our department Community Care Licensing Division (CCLD) and other public agency during the meeting it was discuss the facility is to submit 2 out of 3 documents currently required for admission due to COVID 19; ALW Verification of Approval, Vaccination Card, and/or Declination of Vaccination before admission, the day of, or 24 hours after admission. LPA conducted document review for R1's date of admission is 7/22/21, facility added R1 to line list and schedule 1st dose of vaccination same day and emailed attachments of ALW and vaccination card on 8/4/21 after it was received from placing agency. R2's date of admission is 7/16/21, facility emailed attachments of ALW agreement and vaccination card on 7/16/21. R3's date of admission is 7/21/21 emailed attachments of ALW agreement and date of R3's schedule for 1st dose of vaccine. R4's date of admission is 7/30/21 emailed attachments of vaccination record noted facility was waiting for ALW documents on 7/30/21, facility email ALW document on 8/4/21 after receiving from placing agency. R5's date of admission 7/27/21 email attachments of ALW agreement letter and immunization record on 7/28/21. After review of documentation and emails it was observed facility was not able to submit all documents requested by public agency since facility was waiting for documentation to be send to the facility and it was submitted upon receiving it within 24 hours.

Based on LPA's records review 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 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: 09/15/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2021

LIC9099 (FAS) - (06/04)

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