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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607655
Report Date: 11/29/2022
Date Signed: 11/29/2022 03:10:22 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
05/16/2022 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20220516134857
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:
11/29/2022
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Lori Lackey - Assistant Administrator TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident sustained unexplained bruising while in care.
Resident was handled in a rough manner while in care.
Resident's Representative was not notified of resident's injury.
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA Flores met with Lori Lackey Assistant Administrator and explained the reason for the visit.

The investigation consisted of the following: On 5/18/22 LPA FLores conducted an initial complaint investigation visit and conducted a health and safety check tour of the facility, requested staff/resident roster, and documents for resident #1(R1) physician's report, appraisal needs and care plan, preappraisal, face sheet, functional capability assessment, clinical flex notes, notification to physician and family,and incident reports.
On 5/16/22 Investigation Bureau accepted complaint for full investigation of two allegations. During the investigation assigned Investigator Edward Hector from the Investigaiton Bureau (IB) contacted San Gabirel Valley Medical Center, Broadway Healthcare Center on 5/27/22. On 6/13/22 IB interviewed R1's responsible party, administrator, staff #2, #3. On 6/16/22 IB investigator reviewed documents requested.
(CONTINUED LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022
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-20220516134857
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: 11/29/2022
NARRATIVE
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The investigation revealed the following: Regarding allegation: Resident sustained unexplained bruising while in care. It is alleged that upon hospital staff uncovering R1's chest, R1 "had a very large ecchymotic (bruising) all over chest, going across, like in a "band" pattern. Facility documents reviewed revealed that on 4/26/22 notes revealed staff #3 attempted to use lift on R1, S3 decided not to use lift and called for help as R1 slipped off lift. On 6/13/22 facility's administrator stated "S3 placed R1 in the Hoyer Lift and the belt or sling kept sliding form her abdomen to her chest area." Administrator also stated that as a result of using hoyer lift R1 sustained bruises in her chest. Interview with S2 conducted on 6/13/22 revealed S2 had observed a little bruising on 4/26/22 and four days later verbally notified supervisor that bruising began to enlarge and spread across the chest. On 6/14/22 S3 stated that R1's transfer had changed as previously S3 was able to transfer with the assist of R1 standing on R1's own power. However, "currently R1 could not push or support her own weight, and R1's body is as dead weight". S3 stated R1 was been provided bed baths due to current R1's status and on 4/25/22 R1 had a "bad bowel movement that a shower was necessary". After shower S3 attempted to transfer R1 from shower chair to wheelchair with hoyer lift. S3 stated to have experience using hoyer lift and to use the hoyer lift with R1 on 4/25/22. Hospital intake documentation dated 5/6/22 noted R1 had "ecchymosis accross the chest and upper arms." No mention of suspected elder abuse was noted on intake.

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.

Regarding allegation: Resident was handled in a rough manner while in care. It is alleged R1 sustained this severe bruising on chest after being handled very roughly, several times, probably while being lifted "more than once". Facility documents reviewed revealed that on 4/26/22 notes revealed S3 attempted to use the lift on R1, and S3 decided not to use lift and called for help as R1 slipped off lift. On 6/13/22 facility's administrator stated "S3 placed R1 in the Hoyer Lift and the belt or sling kept sliding from her abdomen to her chest area." Administrator also stated that as a result of using hoyer lift R1 sustained bruises in her chest. On 6/14/22 S3 stated that R1's transfer had changed as previously S3 was able to transfer with the assist of R1 by standing on R1's own power. However, currently R1 could not push or support her own weight, and R1's body is as "dead weight". S3 was providing bed baths due to current R1's status and on 4/25/22 R1 had a bad bowel movement that a shower was necessary instead of a bed bath. After shower S3 attempted to transfer R1 from shower chair to wheelchair with hoyer lift. S3 stated to have experience using hoyer lift and to use the hoyer lift with R1 on 4/25/22 for the first time as R1 did not required before.
(CONTINUED ON LIC 9099C)
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20220516134857
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: 11/29/2022
NARRATIVE
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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.

Regarding allegation: Resident's Representative was not notified of resident's injury. It is alleged responsible party was never informed by the facility that R1 had this bruising. On 6/13/22 S2 stated that after notifying administration regarding bruising S2 was notified that the bruising had been documented, family was notified, and R1's physician had been contacted. Incident Report dated 4/26/22 notes R1's physician and both family members were notified. On 4/26/22 facility notified physician via phone call and sent an email with pictures of bruises. Facility's flex notes noted that on 4/26/22 at 9:10am staff contacted family representative #1 and family member #2 was present during the call with family representative #1. Interview conducted on 6/13/22 with family representative #1 notes family representative #1 was notified on 4/26/22 of the incident and of bruising and was notified that family representative #2 was present at the facility.

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 was conducted with Lori Lackey Assistant Administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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