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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607655
Report Date: 08/10/2022
Date Signed: 09/22/2022 01:30:46 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
06/19/2020 and conducted by Evaluator Elizabeth Ceniceros
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200619080818
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: 120DATE:
08/10/2022
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Asst. Administrator (Lori Lackey).TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility failed to report resident with scabies to local public health department.
INVESTIGATION FINDINGS:
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***THIS IS AN AMENDED REPORT***Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Staff #1 (S1: Malou Bernardo, Business Office Manager); as Administrator (A1: Virginia Garcia) was unavailable, but, LPA/RA was later met by Asst. Administrator (A2: Lorie Lackey). LPA/RA spoke to A2 prior to entering the facility to conduct a risk assessment. A2 informed LPA/RA that the facility had a positive COVID case by a staff member on 08/05/22; however, no new cases at this time nor any residents or staff members have symptoms. An initial 10-Day virtual visit was conducted by LPA Angelica Rea on 06/24/20 (via telephone) with Administrator Garcia due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures.

The purpose of this visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegation. LPA/RA interviewed Asst. Administrator (A2: Lorie Lackey), Staff #1 (S1: Malou Bernardo, Business Office Manager), Staff #2 (S2: Elizabeth Kirk, Nursing Supervisor), and Staff #3 (Manuel "Tony" Ardon, former A.M. Nursing Supervisor) between 9:00 a.m. - 10:00 a.m. LPA/RA could not
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Araceli RamirezTELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
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 3
Control Number 28-AS-20200619080818
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: 08/10/2022
NARRATIVE
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interview (former) Resident #1 due to the resident's passing on 07/14/22. LPA/RA reviewed (former) R1's records between 10:00 a.m. - 11:00 a.m. and obtained copies of pertinent documents: Physician’s Report, Admissions Agreement, Emergency I.D. & Information, Appraisal Needs and Services Plan, Clinical Flex Notes, and Dermatologist Notes; Staff and Resident rosters.

Regarding Allegation #1: this investigation revealed concerns of unreported scabies had been diagnosed to Resident #1 on 06/05/20 and not reported to the Public Health Department. Resident #1's skin condition was discussed with Administrator Garcia, Asst. Administrator Lackey, and Staff #3 relating to Resident #1's scabies treatment. Administrator Garcia stated that Resident #1 had been in isolation (in a private room) since the day of the "suspected" (not confirmed) scabies diagnosis, effective 06/05/20. Resident #1's responsible persons were informed by Staff #3 that facility staff monitor the resident during showers and a "fully body skin check" is conducted on a monthly basis. A review of Resident #1's Physician's Report (dated 07/14/21) documented under, "Physical Health Status" that Resident #1 had no history of skin condition or breakdown. A review of Resident #1's Appraisal/Needs and Services Plan (dated 01/14/22) documented under, "Physical Health" that Resident #1 was at risk for skin breakdowns due to incontinence and immobility. A review of Resident #1's "Clinical Flex Notes" (dated 06/05/20) documented the onset of "suspected" scabies diagnosis by the resident's Dermatologist and reported "just based on clinical presentation - did not do biopsy to confirm" scabies. When facility reported it to the Public Health Department, two (2) nurses came on the phone who said that it wasn't necessarily being lodged against the facility; as no other residents had scabies. This is a precaution. If only one (1) incident of scabies can be documented then the facility did not have an obligation to report it. Asst. Administrator Lackey indicated that it's been reported by the home health nurse (dated 07/22/22) that Resident #1 had been diagnosed with Bullous Pemphigoid.

Based on the evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has not been met; therefore, the allegation of OTHER: Facility failed to report resident with scabies to local public health department is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report was provided to Asst. Administrator (Lorie Lackey).

SUPERVISOR'S NAME: Araceli RamirezTELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20200619080818
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: 08/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/24/2022
Section Cited
CCR
87211(a)(2)
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Reporting Requirements: Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This
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Licensee/Administrator shall read Title 22, Section "Reporting Requirements" and send a written statement to CCL by the POC date - no later than 08/24/22.
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This requirement is not met as evidenced by:

Dermatologist reported "suspected scabies just based on clinical presentation - did not do biopsy to confirm"; therefore, facility did not report it to the Public Health Department.
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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: Araceli RamirezTELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3