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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607655
Report Date: 01/25/2023
Date Signed: 01/25/2023 02:55:34 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
03/03/2021 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20210303163807
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: 127DATE:
01/25/2023
ANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Virginia Garcia - Administrator TIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident suffered a fracture while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Flores and Licensing Program Manager (LPM) Tony Vasallo conducted an informal office meeting to deliver findings for this complaint and met with Virginia Garcia Administrator.

The investigation consisted of the following: On 3/4/21 LPA Flores conducted a video call which consisted of a Health and Safety check by conducting a tour of the facility. LPA observed that the facility is in good repair and clean. LPA requested staff/resident rosters and the following documents for residents #1,#2,#3,#4,#5,#6, Caregiver Logs for February 2021, Incident Reports, Face Sheet, Hospice Service Notes. On 3/4/21 the investigation was assigned to Investigator Edward Hector, who conducted interviews with Administrator, resident #1 (R1), staff members #1,#2 (S1, and S2) and collected hospice documents, physician report dated 3/2/21, facility's flex notes, hospice documents for resident #1(R1). On 2/18/22 a referral was made to the department's program clinical consultant. (CONTINUED ON LIC 9099C)
Substantiated
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: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
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 5
Control Number 28-AS-20210303163807
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: JASMIN TERRACE AT EL MOLINO
FACILITY NUMBER: 197607655
VISIT DATE: 01/25/2023
NARRATIVE
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On 1/10/23 LPA requested physician's report dated and hospice documents for Grigmar Hospice Care. On 1/25/23 LPA delivered findings for the above allegation(s).

The investigation consisted of the following: Regarding allegation: Resident suffered a fracture while in care. It is alleged a left hip fracture involving R1 resulted on a serious bodily injury. Interviews revealed that on 2/23/21 R1's family member visited at around 5:00pm and found R1 in gery chair with a robe on and staff was in the bathroom at the time of the visit. Family member notified administrator of incident. At 7:40pm family member informed facility staff that R1 had pain in left hip, facility staff notified family member that R1 had not have any falls or injuries. R1's physician was at the facility checking other residents and around 7:40pm was called in to check in on R1 and evaluated R1. Physician at that moment did not think there was a fracture, however physician ordered an x-ray to determine if there was a fracture. On 2/24/21 at 12:10am facility received x-ray results noting "acute left hip fracture". On 2/24/21, R1 was taken to the hospital for treatment. R1 was under Grigmar Hospice care at the time. Hospice notes dated 2/23/21 at 9:10pm note R1 had swelling of the left hip and showed facial grimace when moving or lifting left leg. Administrator conducted an internal investigation on 2/24/21 and did not find evidence that S1's neglect or actions caused R1 to sustain a hip fracture. Administrator also stated not observing any bruising or evidence of a fracture on 2/23/21. Administrator advised that staff are to conduct a 2 person assist when showering R1 and it was discovered S1 conducted the shower alone on 2/23/21. R1 was unable to be interviewed due to R1's cognitive skills. Interview with S1 revealed, S1 stated staff is to utilize a 2 person assist when showering the residents. However, on 2/23/22 S1 did not ask for assistance to provide R1's shower. Documents review revealed R1 has a history of hip fracture and osteoporosis per physician's report dated 3/2/21. Radiology report dated 2/23/21 notes an acute left hip fracture.

Based on interviews and review of documentation regarding R1, the preponderance of evidence standard has been met, therefore, the allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D.

***An immediate Civil Penalty of $500.00 is being issued today. Refer to LIC 421IM***

An exit interview was conducted with Virginia Garcia Administrator and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20210303163807
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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: 01/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/26/2023
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities shall...:(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidence by:
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Licensee will ensure facility's plan of operation identify the number of caregivers necessary to provide assistance with transfer and will submit a copy by 1/26/23. Number of caregivers should be identified in care plan and discuss with caregivers. Administrator will provide hoyer lift training for staff and will submit copies by 2/1/23.
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Based on interviews, and documents reviewed the licensee failed to ensure R1 did not sustained a hip fracture while in care which poses an immediate health, safety, or personal rights 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: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
03/03/2021 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20210303163807

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: 127DATE:
01/25/2023
ANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Virginia Garcia - Administrator TIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
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5
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9
Facility fail to notify responsible party of change in condition
Facility has insufficient staff
INVESTIGATION FINDINGS:
1
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5
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12
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Licensing Program Analyst (LPA) Mary Flores and Licensing Program Manager (LPM) Tony Vasallo conducted an informal office meeting to deliver findings for this complaint and met with Virginia Garcia Administrator.

The investigation consisted of the following: On 3/4/21 LPA Flores conducted a video call which consisted of a Health and Safety check by conducting a tour of the facility. LPA observed that the facility is in good repair and clean. LPA requested staff/resident rosters and the following documents for residents #1,#2,#3,#4,#5,#6, Caregiver Logs for February 2021, Incident Reports, Face Sheet, Hospice Service Notes. On 3/4/21 the investigation was assigned to Investigator Edward Hector, who conducted interviews with Administrator, resident #1 (R1), staff members #1,#2 (S1, and S2) and collected hospice documents, physician report dated 3/2/21, facility's flex notes, hospice documents for resident #1(R1). On 2/18/22 a referral was made to the department's program clinical consultant. (CONTINUED ON LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023
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 5
Control Number 28-AS-20210303163807
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: JASMIN TERRACE AT EL MOLINO
FACILITY NUMBER: 197607655
VISIT DATE: 01/25/2023
NARRATIVE
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On 1/10/23 LPA requested physician's report dated and hospice documents for Grigmar Hospice Care. On 3/18/23 LPA delivered findings for the above allegation(s).

The investigation revealed the following: Regarding allegation: Facility fail to notify responsible party of change in condition. It is alleged family member was not notify of fracture upon x-ray results were received. Responsible party stated that from 2/23/21 to 2/24/21 between 11:00pm to 8:30am was not notify of x-ray results or provided an update on R1's change in condition. Documents review revealed facility's flex notes dated 2/24/21- 12:10am note facility received x-ray results noting "acute left hip fracture". Upon receiving the results facility staff contacted physician to notify the x-ray results and physician requested facility notified responsible party. Per facility's notes staff left a voice message for R1's responsible party, notifying to contact the physician in the morning of 2/24/21 as requested by the physician to discuss R1's treatment options.

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: Facility has insufficient staff. It is alleged facility does not have sufficient staff to provide care to the residents. During interviews conducted administrator stated that on 2/23/21 S1 was to provide shower with a 2 person assist and staff did not requested assistance, the incident would have resulted in a third disciplinary notice if S1 had not resigned. S2 who has provided consistent care for R1 stated to have not conducted transfers for R1 around 2/23/21. However S2 stated, whenever needing to transfer R1 out of bed S2 has always provided transfer with a 2 person assist. On 2/23/21 S1 stated to have proceeded to provide shower without requesting assistance from other staff. Documents review revealed February's caregiver schedule for 2/23/21, notes 8 caregivers on duty for the morning shift, 7 caregivers on duty in the evening shift, and 4 caregivers in the night shift. Per administrator during the morning shift each caregiver was providing care for about 12 residents and during the evening shift each caregiver was assigned to at least 15 residents for care.

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 Virginia Garcia Administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5