197607655-8-15-2023-28-AS-TVAO-CUWQAT-20230821120027

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607655
Report Date: 08/15/2023
Date Signed: 08/15/2023 03:12:06 PM

Unsubstantiated

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
06/01/2022 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20220601164319

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: 137	DATE:	08/15/2023
		UNANNOUNCED	TIME BEGAN:	01:01 PM
MET WITH:	Virginia Garcia - Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff not providing adequate service to resident in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegation. LPA met with administrator and explained the reason for the visit.

The investigation consisted of the following: On 6/8/22 LPA Flores requested a copy of staff/resident roster, conducted interviews with Assistant Administrator(S1), resident #1-11 (R1-R11), staff #2 (S2) and requested copies of the following documents: Admission Agreement, Identification and Emergency Information, Appraisal Needs and Care Plan, Flex Notes for R1 and Foot and Ankle Care logs. On 8/15/23 LPA Flores interview staff #3-#5(S3-S5) and delivered findings.

The investigation revealed the following: Regarding allegation: Staff not providing adequate service to resident in care.
(CONTINUED ON LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220601164319

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: 08/15/2023

NARRATIVE

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It is alleged R1 had two layers of clothes on, hair not combed, pressure sock put on wrong and toenails were not cut when family member visited. Interviews conducted on 6/8/22 with residents revealed 11 out of 11 residents interviewed stated staff provides assistance with changing clothes, showers, and Activities of Daily Living (ADLs). Residents also stated a podiatrist provides visits once a month to cut their toenails. 2 out of the 11 residents interview stated to not need assistance with cutting their toenails because they cut them themselves. Administrator assistant and Wellness Director stated staff provide assistance with ADLs by showering, grooming, and changing clothes in the morning. A podiatrist is in rotation who provides services for cutting toenails every 6 weeks for residents. Staff makes notes when residents refuse services. Interviews with additional staff revealed staff assist with changing clothes, showers, and that podiatrist is notified when residents need to cut their toenails. Caregiver (S3) stated to provide care for R1 consistently. Although S3 has come across R1 wearing layers of clothes. S3 has redirected R1 and assisted with removing additional layers. However, when R1 refuses S3 provides time and returns to assists with removing additional layers and R1 is compliant at the time. Document review revealed, physician's report dated: 6/22/21 notes R1 is able to communicate his/her needs and follow instructions. R1 seems to be able to perform most ADLs and needs assistance with showers. Physician's report dated: 6/2/22 notes a change in condition and R1 no longer follows instructions. No other changes were noted. Individual Service Plan dated: 3/4/22 notes staff is to assist R1 three times per week with grooming and supervisors will ensure ADLs are completed daily. It also notes staff will redirect R1 to current situations and reality as needed. Foot and Ankle Care logs dated 2/3/22, 3/3/22, 5/3/22 note R1 received services from the podiatrist on those dates.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

LIC9099 (FAS) - (06/04)

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