197607655-8-2-2022-28-AS-RORN-CPT2P6-20230310163347

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607655
Report Date: 08/02/2022
Date Signed: 08/02/2022 04:58:37 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
01/04/2022 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20220104133920

FACILITY NAME:	JASMIN TERRACE AT EL MOLINO		FACILITY NUMBER:	197607655
ADMINISTRATOR:	VIRGINIA GARCIA		FACILITY TYPE:	740
ADDRESS:	245 S. EL MOLINO AVE.		TELEPHONE:	(626) 578-0460
CITY:	PASADENA	STATE: CA	ZIP CODE:	91101
CAPACITY:	206	CENSUS: 119	DATE:	08/02/2022
		UNANNOUNCED	TIME BEGAN:	08:58 AM
MET WITH:	Lori Lackey - Assistant Administrator		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Resident care needs are not being met

INVESTIGATION FINDINGS:

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Licensing Program Analyst(LPA) Mary Flores conducted an unonnounced complaint investigation visit regarding the above allegation(s). LPA met with Lori Lackey assistant administrator and explained the reason for the visit.

The investigation consisted of the following: On 1/5/22 LPA Flores conducted a tour of rooms#130,132,138,260, and 263 with Virginia Garcia administrator, reviewed files for Resident #1(R1), #2(R2), #3(R3), #4(R4), and requested copies of the following documents for R1, R2,R3,R4: Face sheet, physician's report, preplacement appraisal information, individual service plan assisted living waiver, appraisal/needs and care plan, hospital discharge, incident reports, other reports, and facility's clinical flex notes. On 8/2/22 LPA Flores interviewed resident #1(R1),#2(R2),#3(R3),#4(R4),#5(R5),#6(R6),#7(R7),#8(R8),#9(R9),#10(R10),#11(R11) and staff #1(S1),#2(S2) #3(S3),#4(S4),#5(S5),#6(S6).

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

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 6

Control Number 28-AS-20220104133920

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: 08/02/2022

NARRATIVE

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The investigation revealed the following: Regarding allegation: Resident care needs are not being met. It is alleged resident was scheduled for surgery and physician's instructions were for resident to fast, staff did not pay attention to this issue, and fed resident delaying surgery. Interview with residents revealed 5 out of 11 residents stated to have their needs met by facility and staff. 5 out of 11 residents were unable to respond due to cognitive skills and 1 out of 11 residents stated not receive care from staff at the facility. Interviews with staff revealed 4 out of 6 staff stated they are familiar with the residents care plan and attempt to meet their needs. Assistant Administrator that there was a lack of communication with all kitchen staff which prevented server from retaining breakfast from resident the morning of surgery. Wellness director stated that the staff were instructed the night before to prepared the resident for surgery and retain food intake in the morning. However, caregiver and server did feed the resident in the morning. Document review revealed Flex notes had notes regarding surgery and instructions for R1. During internal investigation caregiver and server admitted to have not realize and fed R1 prior to the surgery. An employee warning notice forms were observed dated 10/19/21 for caregiver and server.

Based on interviews conducted and documents reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 8 are being cited.

Exit interview conducted with Lori Lackey Assistant Administrator and a copy of the report, LIC 9099D, appeal rights were provided.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 6

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
01/04/2022 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20220104133920

FACILITY NAME:	JASMIN TERRACE AT EL MOLINO		FACILITY NUMBER:	197607655
ADMINISTRATOR:	VIRGINIA GARCIA		FACILITY TYPE:	740
ADDRESS:	245 S. EL MOLINO AVE.		TELEPHONE:	(626) 578-0460
CITY:	PASADENA	STATE: CA	ZIP CODE:	91101
CAPACITY:	206	CENSUS: 119	DATE:	08/02/2022
		UNANNOUNCED	TIME BEGAN:	08:58 AM
MET WITH:	Lori Lackey - Assistant Administrator		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Resident was assaulted by another resident
Facility is in disrepair

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 28-AS-20220104133920

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: 08/02/2022

NARRATIVE

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The investigation revealed the following: Regarding allegation: Resident was assaulted by another resident. It is alleged R1 wandered into R12's room on 9/4/21 and 11/6/21 was assaulted because R1 did not know which room R1 was in. R1 had facial lacerations, a busted lip, bruises on neck and arms. Interviews with residents revealed 7 out of 11 residents stated to have not been threaten by residents physically or observed residents in altercations. 2 out of 11 residents stated that there has been incidents when a resident walks into their room but has not been aggressive and leaves prior staff arriving to assist. 2 out of 11 residents were unable to answer due to cognitive skills. Interviews with staff revealed 2 out of 6 staff interview stated incidents did take place, and steps were taken to prevent other incidents from happening after the initial incident. 2 out of 6 staff stated not to be familiar with those incidents, however R1 may have some aggressive behaviors from time to time in which resident needs to be provided space. 2 out of 6 staff interview stated not to be familiar with the incidents. Documents review revealed incident reports were noted and submitted to the department for incidents on 9/4/11 and 11/6/21, in addition to incident report a report of suspected abuse (SOC 341) and an email to the local ombudsman (LTCO) was submitted on 11/8/21 to the proper agencies regarding incident. R12 was admitted to the Geriatric Psych Unit after the incident on 11/6/21 and had previously been admitted on 7/1/21 due to aggressive behaviors. R12 was under care of primary physician and psychiatric. Picture dated 9/4/21 provided by the facility shows redness on left cheek, no bruises or lacerations were observed. No other pictures were provided. Police was contacted on 11/6/21 by R1's responsible party and a report was created, however police officer stated no action can be taken due to R12's cognitive skills.

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 is in disrepair. It is alleged the facility had a sewage leak 11/30/21 where she needed to be moved to another room. Interviews with residents revealed 6 out of 12 residents were unable to answer due to cognitive skills and 5 out of 6 residents stated facility is in good repair. Interviews with staff revealed 5 out of 6 staff stated facility is in good repair and 1 out of 6 stated on 11/30/21 upon R1 and responsible party returning to room after being out all day noticed there was water on R1's room floor, R1 was moved temporarily to another room and a second incident happened a week after returning to the same room in which toilet overflowed. Plumber stated that toilet overflowed both times due to paper towels being flush down the toilet. Resident was moved to a different room after the second incident and paper towels were removed to avoid other incidents. On 1/5/22 LPA Flores tour the facility and observed residents' bathrooms in five rooms working properly. The toilet flooded due to paper towels and facility took measures to repair the toilets and

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 28-AS-20220104133920

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: 08/02/2022

NARRATIVE

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provided a different room while bathroom was being redone after the first incident and a different room was provided as requested by R1's responsible party after the second incident.

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 Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 28-AS-20220104133920

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: 08/02/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/02/2022 Section Cited CCR 87465(a)(2)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility... for assistance in obtaining such care, by compliance with the following:(2) The licensee shall provide assistance in meeting necessary medical and dental needs. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator conducted internal investigation and wrote warning notice form to staff responsible for not meeting R1's needs on 10/19/21. Deficiency cleared.
	8 9 10 11 12 13 14	Based on interviews and documents reviewed licensee failed to ensure R1 did not have food intake in the morning prior to surgery which poses a potential health, safety or personal rights risk to the persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2022

LIC9099 (FAS) - (06/04)

Page: 6 of 6