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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607655
Report Date: 12/14/2021
Date Signed: 12/14/2021 03:47:32 PM

Substantiated


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
11/29/2021 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20211129154345
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:
12/14/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Virginia Garcia - Administrator TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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The alarm batteries were dead.
Facility has pest infestations.
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations.

The investigation consisted of the following: On 12/1/LPA Flores requested staff/resident roster. LPA and administrator conducted a tour of the facility and check each emergency exit doors and exit door on the second floor which exits the patio. LPA and administrator toured the kitchen and common areas in the first floor. LPA requested copies of incident reports submitted to the department regarding pest in the last year and pest control reports for the last six months. On 12/6/21 LPA Flores interview pest control agency expert. 12/14/21 LPA interview staff #1,#2,#3,#4,#5 and residents #1,#2,#3,#4,#5

The investigation revealed the following: Regarding allegation: The alarm batteries were dead. It is alleged that appears to be no functioning alarm system in place. Interview with administrator revealed the batteries of the alarm in the door leading to the courtyard needed to be change and found they were not working during a visit from the local ombudsman. (CONTINUED LIC 9099)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
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 5
Control Number 28-AS-20211129154345
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: 12/14/2021
NARRATIVE
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Janitor stated that the batteries were recently replaced after realizing batteries were not working during a visit from the local ombudsman. Interviews with staff revealed 2 out of 5 staff interview stated that batteries do not work sometimes. 2 out of 5 have not notice if batteries are not working, and 1 out of 5 staff stated batteries always work. Interviews with residents revealed 2 out of 5 residents have noticed the alarms go off and 1 out of 5 residents stated to not have heard the alarms for the doors go off at any time. 2 out of 5 residents were unable to respond due to cognitive skills.
Based on LPA's observations, and interviews, conducted the preponderance of evidence standard has been
met, therefore the above allegation(s) are found Substantiated.

Regarding allegation: Facility has pest infestation. It is alleged facility has an infestation of mice/rats, and bed bugs. On 12/6/21 LPA Flores interviewed pest control expert at Dewey Pest Control who stated the facility has had continue services for pest control with their agency for many years. Around June facility had observed a few rats and inquired services. However, the expert does not consider rats/mice to be an infestation, as rodents reside in the neighborhood and facility has bite stations throughout. Regarding Bed bugs the facility is currently going under treatment and there is currently an infestation as live bed bugs were found in 9 rooms of the facility. LPA review pest control invoices for the month of November 2021. Interviews with staff revealed 3 out of staff have not observed rats/mice at the facility and 2 of the 3 have not observed bed bugs, however 1 out of the three has heard that there are bed bugs in rooms. 2 out of 5 staff stated to have observed rats inside and in the patio of the facility. Interviews with residents, 3 out of 5 residents stated to have not observed any pest at the facility. 1 out of 5 residents stated to have observed mice a while back. 1 out of 5 residents were not able to respond due to cognitive skills.

Based on LPA's observations, and interviews, conducted the preponderance of evidence standard has been
met, therefore the above allegation(s) are found Substantiated. California Code of Regulations Title 22,
Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Immediate Civil Penalties have been assess for Repeat Violation within 12 months for $250.

Exit interview was conducted with Virginia Garcia administrator and a copy of the report, LIC 9099D, and Appeal Rights was provided
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
11/29/2021 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20211129154345

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:
12/14/2021
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Virgnia Garcia - AdministratorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not provide adequate supervision.
Facility is not reporting infestations to appropriate agencies.
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegations.

The investigation consisted of the following: On 12/1/21LPA Flores requested staff/resident roster. LPA and administrator conducted a tour of the facility and check each emergency exit doors and exit door on the second floor which exits the patio. LPA and administrator toured the kitchen and common areas in the first floor. LPA requested copies of incident reports submitted to the department regarding pest in the last year and pest control reports for the last six months. On 12/6/21 LPA Flores interview pest control agency expert. On 12/14/21 LPA interview staff #1,#2,#3,#4,#5 and residents #1,#2,#3,#4,#5.

The investigation revealed the following: Regarding allegation: Staff did not provide adequate supervision. It is alleged that a resident was observed behind a closed emergency exit door on the second floor and staff did not appear to be aware of resident's location. LPA observed exit door near room #236 which exits into a staircase
(CONTINUED LIC 9099)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20211129154345
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: 12/14/2021
NARRATIVE
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and leads to the facility's courtyard. Interview with administrator revealed the emergency exit door is under egress system however the batteries for the alarm were not working. The door at the bottom of the staircase of that emergency door is to be kept unlock as requested by fire department. Egress system is attached to a signal system in the front desk which alerts the staff at the front desk and staff notifies caregivers via radio. Interviews with staff revealed 4 out 5 stated residents are check every two hours, they respond to alarm at emergency doors right away, and 2 out of the 4 stated staff get notify via radio regarding residents observations on cameras. 1 out of 5 staff stated when alarms go off staff respond timely. Interviews with residents revealed 3 out of 5 residents stated staff check on them regularly throughout the day. 2 out of 5 residents were not able to respond due to cognitive skills.

Based on LPA's observations, and interviews, conducted the preponderance of evidence standard has been
met, therefore the above allegation(s) are found UNSUBSTANTIATED.

Regarding allegation: Facility is not reporting infestations to appropriate agencies. It is alleged facility did not reported rat/mice infestation to Community Care Licensing and/or Pasadena Public Health as facility did not consider it to be an issue. On 12/6/21 LPA Flores interviewed pest control expert at Dewey Pest Control who stated the facility has had continue services for pest control with their agency for many years. Around June facility had observed a few rats and inquired services. However, the expert does not consider rats/mice to be an infestation, as rodents reside in the neighborhood and facility has bite stations throughout. Regarding bed bugs on 12/3/21 service agreement was created to treat 9 rooms out of 94 LPA review pest control invoices for the month of November and December 2021 and emails send to Department of Public Health and Community Care Licensing representatives on 11/24/21 and 11/26/21 regarding pest control visit and treatment plan. Facility provided hard copy of incident report dated 11/16/21 during the initial visit however no transmission report was provided. Although the facility did not provided a hard copy of incident report to the department. There are email communication regarding bed bug findings and treatment.

Based on LPA's observations, 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 and a copy of this report was provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20211129154345
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: 12/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/14/2021
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation: (a) (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 requirement is not met as evidence by:
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Licensee will ensure pest is under control at all times and to maintain professional pest control services as necessary. Licensee provided copies of pest control service and pest control infection sheet dated 12/13/21 clearing the facility of bed bugs. Deficiency cleared on 12/14/21.
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Based on interviews conducted Licensee did not ensure facility was free of bed bugs in 9 rooms, which poses an immediate Health, Safety, or Personal rights risk to person in care.
*Immediate Civil Penalties assess for repeat violation of $250.*
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Type A
12/14/2021
Section Cited
CCR
87705(j)
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87705 Care of Persons with Dementia: (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.



This requirement is not met as evidence by:
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Licensee will ensure alarm system is in working condition. Administrator will maintain a log to track batteries live and will submit log to the department in 7 days. During the visit of 12/1/21 LPA observed alarm working.
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Based on interviews Licensee did not ensure exit door's (to courtyard) alarm batteries were working properly which poses an immediate Health, Safety, or Personal risk to the persons in care.
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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: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5