197607655-12-17-2021-28-AS-SCOL-CDQMUB-20220422095451

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607655
Report Date: 12/17/2021
Date Signed: 12/17/2021 01:24:09 PM

Unsubstantiated

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
12/13/2021 and conducted by Evaluator David Sicairos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20211213131957

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: 105	DATE:	12/17/2021
		UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Virginia Garcia; Administrator		TIME COMPLETED:	01:37 PM

ALLEGATION(S):

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Resident sustained injury while in care due to lack of supervision.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) David Sicairos conducted an initial complaint investigation regarding the allegation listed above. LPA met with Malou Bernardo Business Office Manager and explained the reason for the visit. Administrator Virginia Garcia arrived shortly thereafter.

The investigation consisted of the following: during today's visit, LPA toured the facility which included a random sample of resident rooms and common areas. LPA reviewed Resident #1 (R1) file and obtained copies of the following documents: FACE Sheet, Physician's Report, Assisted Living Waiver ISP, Discharge Summary, Incident Report, and Clinical Notes. LPA also obtained copies of Staff & Resident Rosters. LPA interviewed Resident #2 - Resident #6 and Staff #1 - Staff #6 . R1 was not interviewed during today's visit as R1 is currently at a Skilled Nursing Facility and will not be returning to the facility, however LPA interviewed R1's Family Member.

The investigation revealed the following: in regards to the allegation "resident sustained injury while in care due to lack of supervision", it is alleged that on 12/10/21 R1 was found laying on the hallway floor of the facility. (CONTINUED ON 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

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-20211213131957

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: 12/17/2021

NARRATIVE

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R1 was taken to the hospital and was diagnosed with a brain bleed injury. Since October 2021, R1 was residing at a Skilled Nursing Facility for walking rehabilitation. R1 then returned to the facility on 12/09/21. R1 is ambulatory and did not have an assigned one on one caregiver while a resident of this facility. Interview conducted with Administrator revealed that on 12/10/21 R1 suffered an unwitnessed fall around 11:35am. A housekeeper heard a noise in the hallway and saw R1 on the floor. Housekeeper called for help and 911 was immediately called. R1 was transported to the hospital. Interviews with staff members revealed that residents are checked on at least every 2 hours. 5 out of 5 residents interviewed indicated that staff members will assist them with their activities of daily living within a reasonable amount if time. 5 out of 5 residents interviewed indicated that they feel that there is a sufficient amount of staff available at the facility to meet their needs. LPA pulled emergency cord in a random resident room during tour and observed staff responded to the call in less than 5 minutes. LPA did not obtain any evidence during investigation indicating that R1's fall was due to staff neglect or as a result of lack of supervision. Therefore there was insufficient evidence to corroborate with this allegation.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: David Sicairos	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

LIC9099 (FAS) - (06/04)

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