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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607655
Report Date: 12/08/2022
Date Signed: 03/10/2023 01:07:31 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 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: 124DATE:
12/08/2022
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Lori Lackey - Assistant Administrator TIME COMPLETED:
11:30 AM
ALLEGATION(S):
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9
Resident was assaulted by another resident
Resident care needs are not being met
INVESTIGATION FINDINGS:
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8
9
10
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12
13
*This is an amended report of report provided on 8/2/22 to change finding from unsubstantiated to substantiated and provide correct deficiency for allegation Resident was assaulted by another resident, and provide additional information for allegations above.*
On 8/2/22 Licensing Program Analyst(LPA) Mary Flores conducted an unannounced subsequent 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.
(CONTINUED ON LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
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 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
01/04/2022 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20220104133920

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: 124DATE:
12/08/2022
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Lori Lackey - Assistant Administrator TIME COMPLETED:
11:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is in disrepair
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
*This report supersedes report created on 8/2/22 to change finding for allegation Resident was assualted by another resident, and provide additional information on the other two allegations.*
On 8/2/22 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).
(CONTINUED)
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: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
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: 12/08/2022
NARRATIVE
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Regarding allegation: Facility is in disrepair. It is alleged the facility had a sewage leak on 11/30/21 where resident 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 staff stated that on 11/30/21 upon R1 and responsible party returning to room after being out all day, they noticed there was water in R1's room on the floor. Per Assistant Administrator R1 was moved from room #138 temporarily to room #130 on 11/30/21 and a second incident happened a week after upon returning to the R1's assigned room in which toilet overflowed on the second incident. 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, toilets, showers, and faucets were in working condition. Per administrator, plumbing assessment toilets overflowed due to excess paper towels flushed down. After the incident on 11/30/21 facility took measures to repair the toilet and redone the entire bathroom during the repairs R1 remained on room #130. Upon R1 returning to room #138 and second incident happening R1's responsible party requested R1 return and stay in room #130. Plumbing Services invoice dated 12/1/21 notes a hydro jet drain line and other bathroom related work is listed.

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: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 7
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: 12/08/2022
NARRATIVE
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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).

The investigation revealed the following: Regarding allegation: Resident was assaulted by another resident. Based on interviews and information gathered during the investigation, it was determined that R1 has wandering behavior. On 9/4/21, R1 wandered into R12’s room which resulted in R12 assaulting R1. R1 sustained injuries including but not limited to, facial lacerations and bruises. An incident report was submitted as required, however, no plan of action was documented to address this behavior nor was R1’s needs/services plan updated to reflect R1’s change in behavior. During the interview with the wellness director, she indicated that she advised staff to provide additional supervision to R1 after this incident. A second incident occurred on 11/6/21 in which R1 walked into R12’s room resulting in R12 hitting R1. Upon review of the special incident report dated 11/6/21, the plan of action indicated R1 would be closely monitored but did not include preventative measures the facility would take to ensure the safety of the resident. After the facility informed R1’s responsible party about the incident on 11/6/21, R1’s responsible party contacted the Pasadena police department, however, no further action was taken by law enforcement. Documents review revealed R1's Assisted Living Waiver (ALW) needs and care plan dated 6/30/21 does not provide information to address wandering behaviors to prevent R1 from wandering into other residents' rooms. No other notes were found related to providing additional supervision, monitoring, or changes in activities to assist with R1's wandering behavior. An updated needs and care plan was not provided. On 11/18/22 LPA confirm with the ALW coordinator that R1 does not need a higher level of care at this time.

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.

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. (CONTINUED ON LIC 9099C)
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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: 12/08/2022
NARRATIVE
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Assistant Administrator informed LPA that R1 was schedule for surgery on 10/19/21 and there was a lack of communication with all kitchen staff the night of 10/18/21 which prevented server from retaining breakfast from resident the morning of surgery. Wellness director stated that the staff were instructed the night of 10/18/21 to prepared the resident for surgery and retain food intake in the morning of 10/19/21. However, caregiver and server did feed the resident in the morning of 10/19/21. Documents review revealed Flex notes had notes regarding surgery schedule for 10/19/21 and physician's instructions for R1 before the surgery. An internal investigation was conducted and reveal caregiver and server admitted to have not realize and fed R1 prior to the surgery on 10/19/21. 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. This deficiency was noted on LIC 9099D dated 8/2/22.


Exit interview conducted with Lori Lackey Assistant Administrator and a copy of the report, LIC 9099D, appeal rights were provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 7
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: 12/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/22/2022
Section Cited
CCR
87466
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87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs...

This requirement is not met as evidence by:
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Licensee will ensure updated plan care for R1 is review with staff in each shift to ensure that direct care is provided to meet R1's needs. A copy of updated R1's care plan and a copy of staff's sign in log of reviewed care plan is to be submitted to the department by 12/22/22.
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Based on interviews and documents review licensee failed to provide adequate direct care staff to support R1's needs identify in physician's report which poses a potential risk to the health, safety, or personal rights of 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: Tony VasalloTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7