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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607655
Report Date: 03/27/2021
Date Signed: 03/27/2021 03:14:44 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
07/18/2019 and conducted by Evaluator Alma Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20190718114859
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: 107DATE:
03/27/2021
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Virgina GarciaTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Lack of supervision resulting in resident AWOLing multiple times
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alma Gonzalez initiated a telephonic subsequent complaint investigation to deliver investigation findings. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Executive Director Virginia Garcia.

Investigation consisted of the following: During the initial visit conducted on 7/25/19, LPA Gonzalez obtained a copy of Staff and Resident Rosters. LPA obtained a copy of the Resident Roster and Staff Roster. LPA interviewed Executive Director Virginia Garcia and Caregiver Supervisor Rocio Gonzalez. LPA reviewed Resident 1’s (R1) file and collected copies of various documents from R1's file which include: Physician's Report for Residential Care Facilities for the Elderly (LIC602A) and Clinical Flex Notes from 2/28/19 - 7/11/19. LPA was unable to interview R1 due to resident being asleep at the time of LPA visit. LPA interviewed R1's friend that was visiting at the time that LPA attempted to interview R1.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2021
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-20190718114859
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: 03/27/2021
NARRATIVE
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Investigation revealed the following: Regarding allegation, Lack of supervision resulting in resident AWOLing multiple times, there were allegedly two incidents where R1 left the facility undetected and was found hours later by police. LPA review of R1’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) dated 7/18/19 revealed that R1’s primary diagnosis is Alzheimer’s Disease with Wandering and Sundowning Behavior. Interview conducted with Executive Director Virginia Garcia on 7/25/19 revealed that R1 did attempt to AWOL from the facility a number of times but R1 was redirected by staff on all attempts. Interview conducted with Caregiver Supervisor Rocio Gonzalez on 7/25/19 revealed that she only recalls one incident (since R1 has lived at the facility) when R1 was brought back to the facility by the police. She stated that she did not recall exactly when the incident occurred and that it might have occurred when R1 was initially admitted to the facility as he was having trouble getting accustomed to living in the facility. LPA review of Resident roster revealed that R1 was admitted to the facility on 9/1/18. On 6/15/20, LPA Flores requested missing person reports from Executive Director. On 6/22/20, LPA Flores received additional documents via email from Executive Director including an Unusual Incident/ Injury Report dated 10/1/19 that revealed that R1 was brought back to the facility by the police and paramedics at approximately 8:10pm and upon review of facility security camera it was found that R1 kicked the screen of a window in the small TV room and climbed out at approximately 7:10pm.

Based on interviews conducted with Executive Director Virginia Garcia, Caregiver Supervisor Rocio Gonzalez and LPA review of R1’s medical records and Unusual Incident/ Injury Report dated 10/1/19, the preponderance of evidence standard has been met; therefore, the allegation of Lack of supervision resulting in resident AWOLing multiple times is found to be SUBSTANTIATED.



Pursuant to the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited during the visit. (Refer to LIC 9099D).

Due to measures implemented due to COVID-19, exit interview was conducted with Executive Director Virginia Garcia via telephone. A copy of the report was sent via email for signature. Appeal Rights were also provided. A hard copy with signature is on file.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 28-AS-20190718114859
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: 03/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/29/2021
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidenced by:
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Executive Director to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Administrator to submit a faxed or mailed copy of POC by due date.
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Based on interviews, licensee failed to ensure that R1 was accorded safe and healthful accommodations due to R1 AWOLing facility and staff not being aware, which poses an immediate health, safety and personal rights risk to residents in care.
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Type B
04/02/2021
Section Cited
CCR
87211(a)(1)(D)
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Reporting Requirements;.. (a) licensee shall furnish... (1) A written report shall be submitted to the licensing agency...(D) Any incident which threatens the welfare, safety or health of any resident...

This requirement is not met as evidended by:
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Executive Director to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Administrator to submit a faxed or mailed copy of POC by due date.
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Based on interviews conducted and record review, Executive Director failed to furnish a LIC624 Unusual Incident/ Injury Report when client AWOL from facility when initially admitted to the facility, which poses an Immediate Health, Safety or Personal Rights risk to residents 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: Alma GonzalezTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2021
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
07/18/2019 and conducted by Evaluator Alma Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20190718114859

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: 107DATE:
03/27/2021
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Virginia GarciaTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility restrained resident in bed
Facility staff left resident in soiled clothing for an extended period of time
Facility failed to ensure resident could access their food
Facility failed to ensure resident had access to water
Facility staff failed to respond to resident's call in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alma Gonzalez initiated a telephonic subsequent complaint investigation to deliver investigation findings. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Executive Director Virgina Garcia.

Investigation consisted of the following: During the initial visit conducted on 7/25/19, LPA Gonzalez obtained a copy of Staff and Resident Rosters. LPA obtained a copy of the Resident Roster and Staff Roster. LPA interviewed Executive Director Virginia Garcia and Caregiver Supervisor Rocio Gonzalez. LPA reviewed Resident 1’s (R1) file and collected copies of various documents from R1's file which include: Physician's Report for Residential Care Facilities for the Elderly (LIC602A) and Clinical Flex Notes from 2/28/19 - 7/11/19. LPA was unable to interview R1 due to resident being asleep at the time of LPA visit. LPA interviewed R1's friend that was visiting at the time that LPA attempted to interview R1. On 4/21/20, LPA Flores interviewed

(See LIC 9099C for continuation of report)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2021
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-20190718114859
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: 03/27/2021
NARRATIVE
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Activities Staff Alejandra Ceballos by telephone. On 4/22/20, LPA Flores interviewed Activities Staff Erika Trujillo, Office Coordinator Denise Miller, Caregiver Pamela Soto, Caregiver Laura Patino, Housekeeper Edgar Olvera, Housekeeper Diana Espinal and R2-11 by telephone. On 5/29/20, LPA Flores attempted to interview R1’s responsible parties. On 6/22/20, LPA Flores requested and received various documents pertaining to complaint allegations from Executive Director Virginia Garcia. On 7/24/20, LPA Gonzalez interviewed CareMark Healthcare (Hospice Agency) Director of Patient Care Mariam Mangyan by phone and received medical documents pertaining to R1 by email.

The investigation revealed the following: In regard to allegations, Facility restrained resident in bed, it is alleged that R1 was "trapped" in their bed with the rails up. Interview conducted with Caregiver Supervisor Rocio Gonzalez revealed that the only time R1's bed rails were left up was when R1 was sleeping. Caregiver Supervisor stated that staff check on residents every two hours or in between if residents call for assistance. Interview conducted with CareMark Healthcare (Hospice Agency) Director of Patient Care Mariam Mangyan revealed that R1 was prescribed a hospital bed with half rails due to R1 being a fall risk and high risk for falls on 7/5/19. She stated that R1 is confused and can be aggressive at times. She stated hospice agency staff did not report ever seeing R1 left restrained in the bed with the rails up. She stated that R1 was seen by Hospice Agency twice a week. She stated that R1 does have a history of wandering and attempting to go into other resident's rooms. LPA reviewed Physician's Order Form dated 7/5/19 requesting a hospital bed with half rails for R1. Interviews with facility staff revealed that staff conduct rounds and check in on residents at least every two hours or sooner for residents that require a higher lever of care. Based on interviews conducted with facility staff and Hospice Agency staff, there was not enough supportive evidence to concur with the reported allegation.

For the allegation, Facility staff left resident in soiled clothing for an extended period of time, it is alleged that resident was found urine soaked in his bed. Interview conducted with Caregiver Supervisor Rocio Gonzalez revealed that residents are routinely checked on every two hours. She stated that at that time residents that require change of diaper are checked on to determine if they need to change the resident if diaper is soiled. She also stated that she does not recall R1 being left in soiled clothing for an extended period of time. She stated that R1's family and friends regularly visit and have not reported to facility staff that R1 was left in soiled clothing. Interviews with 10 out of 11 residents interviewed stated that they are satisfied with the care and services given by staff, staff check on them regularly and staff are very helpful. Based on
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 28-AS-20190718114859
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: 03/27/2021
NARRATIVE
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Based on interviews conducted with facility staff and residents and LPAs observations, there was not enough supportive evidence to concur with the reported allegation.

For the allegations, Facility failed to ensure resident could access their food and Facility failed to ensure resident had access to water, it is alleged that resident's was found in bed with rails up and food and water were out of reach. Interviews conducted with 6 out of 11 residents revealed that they do not have any issues regarding not having access to food and water. They stated that when food is left for them in their room it is placed in a location that is accessible for them. Interviews with 10 out of 11 residents interviewed stated that they are satisfied with the care and services given by staff, staff check on them regularly and staff are very helpful. Interviews with facility staff revealed that when food and water is brought in to a residents room it is placed in a location that is readily available to residents and within resident's reach. Based on interviews conducted with facility staff and residents and LPAs observations, there was not enough supportive evidence to concur with the reported allegation.


For the allegation, Facility staff failed to respond to resident's call in a timely manner, it is alleged it took over an hour for staff to respond when the red emergency cord was pulled to get assistance. Interviews conducted with 3 out of 11 residents revealed that they have used the call button and staff came to help residents in a timely amount of time. Interviews conducted with 4 out of 11 residents revealed that they do not use the call button but that staff regularly check on them. Interviews conducted with 2 out of 11 residents revealed that they do not need to use the button and that staff are overall helpful. 1 out of 11 residents did not want to be interviewed. Interviews with facility staff revealed that if residents use the emergency cord staff go to residents in a timely manner and do not take over an hour to check on a resident. Staff also stated that they continuously conduct checks on residents every two hours. Interview conducted with Caregiver Supervisor Rocio Gonzalez revealed that residents are routinely checked on every two hours and staff never take more than an hour to check on a resident that has pull their emergency cord. Caregiver Supervisor stated that staff response time is fairly fast and staff/ caregivers will answer the call if staff are busy they will let the resident know it will be a few minutes if its not an emergency. She also stated that if staff do not respond to a call within 20 minutes the front desk is alerted and will call supervisor to see what is going on. Based on interviews conducted with facility staff and residents, there was not enough supportive evidence to concur with the reported allegation.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 28-AS-20190718114859
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: 03/27/2021
NARRATIVE
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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.

Due to measures implemented due to COVID-19, exit interview was conducted with Executive Director Virginia Garcia via telephone. A copy of the report was sent via email for signature. A hard copy with signature is on file.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2021
LIC9099 (FAS) - (06/04)
Page: 7 of 7