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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607655
Report Date: 03/01/2021
Date Signed: 03/09/2021 07:25:51 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
03/11/2020 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200311162111
FACILITY NAME:JASMIN TERRACE AT EL MOLINOFACILITY NUMBER:
197607655
ADMINISTRATOR:VIRGINIA GARCIAFACILITY TYPE:
740
ADDRESS:245 S. EL MOLINO AVE.TELEPHONE:
(626) 578-0460
CITY:PASADENASTATE: CAZIP CODE:
91101
CAPACITY:206CENSUS: 102DATE:
03/01/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Laurie LackeyTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility has cockroaches.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Laurie Lackey.

On 03/23/20, at approximately 1:40 P.M, LPA Irra conducted a telephone interview with the back-up/Assistant Administrator and obtained documentation revelant to this investigation.

During the course of this investigation, LPA interviewed Assistant Administrator, Staff 1 through Staff 8 (S-1 through S-8) and Resident #1 through Resident #7 (R-1 through R-7). LPA also obtained service records from the Dewey Pest Control company.

Refer to LIC 9099C for the continuation of this report
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2021
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 7
Control Number 28-AS-20200311162111
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: 03/01/2021
NARRATIVE
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Allegation: Facility has cockroaches. Staff interviews (7) out of (9) revealed that the facility has had cockroaches. However, interviews revealed that currently there has been less activity (cockroaches) since March 2020. Interviewed Staff indicated that a Dewey Pest Control Company goes to the facility and treats for cockroaches on a monthly basis. Additionally, interviewed Staff indicated that the janitors utilize a special heating machine (Monday through Friday) to prevent cockroach activity. Some interviewed Staff indicated that they observed cockroach activity in the kitchen dishwasher area. Resident interviews revealed that (1) out of (7) has observed cockroach activity. However, the (1) Resident that had observed this activity, was unable to provide additional information (unable to provide location, dates nor time frames). Staff interviews and service records from Dewey Pest Control corroborate this allegation.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated.

The following deficiency is cited per California Code of Regulations, Title 22, Division 6, Chapter 8. Refer to
LIC9099D.

Exit interview was conducted, a copy of Appeal Rights were provided and a copy of this report was sent to Laurie Lackey via e-mail for signature.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 28-AS-20200311162111
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: 03/01/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/08/2021
Section Cited
CCR
87303(a)
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Maintanance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This standard is not met as evidence by:
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Administrator will ensure that the facility continues to have inspections and treatments from Pest Control Company. Administrator to increase the number of treatments to retify this nuisance and provide LPA Irra a written statement (by POC due date) as to how the facility will continue to monitor and treat this matter.
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Staff interviews revealed that the facility has had cockroaches. However, currently there has been less activity (cockroaches) since March 2020. Interviewed Staff indicated that a Dewey Pest Control Company goes to the facility and treats for cockroaches on a monthly basis.
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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: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 7
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
03/11/2020 and conducted by Evaluator Elizabeth Irra
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200311162111

FACILITY NAME:JASMIN TERRACE AT EL MOLINOFACILITY NUMBER:
197607655
ADMINISTRATOR:VIRGINIA GARCIAFACILITY TYPE:
740
ADDRESS:245 S. EL MOLINO AVE.TELEPHONE:
(626) 578-0460
CITY:PASADENASTATE: CAZIP CODE:
91101
CAPACITY:206CENSUS: 102DATE:
03/01/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH: Laurie LackeyTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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2
3
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5
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9
Facility has bed bugs.
No activities are provided to the residents.
There is a urine odor at the facility.
Residents are not getting their needs met.
Food service is inadequate.
Staff is not assisting residents with hygiene.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Elizabeth Irra initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Laurie Lackey. The initial complaint investigation was conducted on 03/23/2020.

On 03/23/20, at approximately 1:40 P.M, LPA Irra conducted a telephone interview with the back-up/Assistant Administrator and obtained documentation revelant to this investigation.

During the course of this investigation, LPA interviewed Assistant Administrator, Staff 1 through Staff 8 (S-1 through S-8) and Resident #1 through Resident #7 (R-1 through R-7).

Refer to LIC 9099C for the continuation of this report
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 28-AS-20200311162111
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: 03/01/2021
NARRATIVE
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Allegation: Facility has bed bugs.
Staff interviews revealed that they have not observed nor have received any complaints/concerns pertaining to this facility having bed bugs. Resident interviews revealed that they have not observed nor have they heard of any complaints/concerns pertaining to this facility having bed bugs. Staff and Resident interviews do not corroborate this allegation.

Allegation: No activities are provided to the residents.
Staff interviews revealed that this facility has been unable to provide as many activities as they were providing pre-COVID 19 to adhere by the mandated social distancing guidelines. However, Staff interviews revealed that the facility has modified the activities that are offered. Per Staff interviews, the current activities provided are as follows: 1:1 morning walks with staff (wearing PPE supplies), exercising while watching exercise videos, watching movies and arts and drafts such as drawing and painting. Interviewed Residents indicated the facility provides exercising, watching movies and arts and crafts. Staff and Resident interviews do not corroborate this allegation.

Allegation: There is a urine odor at the facility.
Staff interviews revealed that this facility is kept clean and odor free. Interviewed Staff indicated that this facility does not have a urine odor nor do staff attempt to mask any odors with disinfectants/cleaning supplies. Interviewed staff indicated that this facility now has more flooring which is easier to upkeep than carpet. Interviewed staff indicated that Housekeepers and Janitors keep this facility clean at all times. Interviewed Residents revealed that this facility is odor free (including the odor of urine). Interviewed Staff indicated they have not received any complaints/concerns in regards to this facility having the odor of urine or any other foul odor. Interviewed Residents indicated this facility does not have any foul odors including the odor of urine. Interviewed Residents indicated they observe staff cleaning this facility daily throughout the day. Staff and Resident interviews do not corroborate this allegation.

Refer to LIC 9099C for the continuation of this report.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 28-AS-20200311162111
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: 03/01/2021
NARRATIVE
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Allegation: Residents are not getting their needs met. Staff interviews revealed that they have not observed nor have received any complaints/concerns pertaining to this facility not meeting Residents needs. Interviewed Staff indicated they assist Residents with their needs such as completing their Activities of Daily Living (cleaning and maintaining Residents' room, assisting Residents in showering, dressing and administrating medications). Interviewed Staff indicated they have not observed nor have received any complaints/concerns pertaining to Residents being left on diapers and/or sitting in wheelchairs in the same place at different times. Interviewed staff indicated that Residents utilizing wheelchairs and/or walkers are on the first floor. Interviewed staff indicated Residents do not "play with their poop" at the dining table nor anywhere in the facility. Interviewed staff indicated that the dinning room is not crowded (most Residents are taken their meals and snacks to their rooms due to COVID-19 to maintain social distancing). Interviewed Staff indicated there are a few Residents have their meals at the dinning area (1 Resident per table to maintain social distancing). Interviewed Staff indicated Residents are clean and not "filthy". Resident interviews revealed that their needs are being met. Resident interviews indicated staff assist with showers, dressing, administering medication, provide (3) meals and (2) snacks, provide activities and so forth. Interviewed Residents indicated their meals and snacks are taken to their rooms. Interviewed Residents indicated they have not observed nor have they received any complaints/concerns pertaining to this facility not meeting Resident needs. Staff and Resident interviews do not corroborate this allegation.

Allegation: Food service is inadequate. Staff interviews revealed that the food service provided to Residents is adequate. Interviewed staff indicated that they have not received any complaints/concerns pertaining to this facility not providing adequate food service. Interviewed staff indicated residents are provided with (3) meals and (2) snacks daily. Interviewed Staff indicated this facility provides a variety of food and also provides substitutions for items that residents prefer to have. Interviewed staff indicated most Residents are taken their meals and snacks to their rooms due to COVID-19 to maintain social distancing. Interviewed Staff indicated there are a few Residents have their meals at the dinning area (1 Resident per table to maintain social distancing). Interviewed Residents indicated the food service is adequate. Interviewed Residents indicated they are provided with (3) meals and (2) snacks and they are able to request substitutions. Interviewed Residents indicated staff take their meals and snacks to their rooms. Interviewed Residents enjoy the meals and snacks that are provided. Staff and Resident interviews do not corroborate this allegation.

Refer to LIC 9099C for the continuation of this report.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 28-AS-20200311162111
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: 03/01/2021
NARRATIVE
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Allegation: Staff is not assisting residents with hygiene.
Staff interviews revealed that they have not observed nor have received any complaints/concerns pertaining to this facility not assisting residents with hygiene. Interviewed Staff indicated they assist Residents with their needs such as completing their hygiene/activities of Daily Living (cleaning and maintaining Residents' room, assisting Residents in showering, dressing and administrating medications). Interviewed Staff indicated they have not observed nor have received any complaints/concerns pertaining to Residents being left on diapers and/or sitting in wheelchairs in the same place at different times. Interviewed staff indicated Residents do not "play with their poop" at this facility. Resident interviews revealed that their hygienic needs are met. Resident interviews indicated staff assist with showers and dressing. Interviewed Residents indicated their meals and snacks are taken to their rooms. Interviewed Residents indicated they have not observed nor have they received any complaints/concerns pertaining to this facility not meeting Resident hygienic needs. Staff and Resident interviews do not corroborate this allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview was conducted, a copy of Appeal Rights were provided and a copy of this report was sent to Laurie Lackey via e-mail for signature.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth IrraTELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7