197607655-4-14-2021-28-AS-MVAO-C28PA7-20210419110814

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607655
Report Date: 04/13/2021
Date Signed: 04/14/2021 10:28:55 AM

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
10/02/2019 and conducted by Evaluator Christine Wong

COMPLAINT CONTROL NUMBER: 28-AS-20191002103652

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:	DATE:	04/13/2021
		UNANNOUNCED	TIME BEGAN:	03:01 PM
MET WITH:	Virginia Garcia- Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident received unexplained injury while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Wong initiated a subsequent complaint investigation to deliver findings on the allegation listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Administrator Virginia Garcia

The investigation consisted of the following: On 10/10/2019, LPA Juan Miramontes conducted an initial 10 days visit and delivered the finding with unsubstantiated finding. During the investigation, LPA Miramontes obtained a copy of the current resident roster and staff roster. Reviewed facility record files for Resident #1-4 (R1-R4). Obtained copies of the following documents physician's report, staff notes, SIR dated 02/17/19 and list of medications Interviews were conducted with Administrator Garcia and with Stafff#1-#3 (S1-S3). On 03/11/21 and 03/16/21, LPA Wong conducted more interviews with three (3) staff, administrator.

(See LIC9099 for continuation)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2021

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-20191002103652

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: 04/13/2021

NARRATIVE

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The investigation revealed of the following: Allegation “Resident received unexplained injury while in care.” LPA interviewed staff and administrator and all reported Resident#1 (R1) did not have any falls or injuries during that period of time. They all reported they have no idea what had happened to R1’s right eye and cheek. The staff also denied seeing any bruise or swollen on R1’s right eye or check the day prior. The administrator also indicated that R1 had been observed sitting in the wheelchair with fist balled up into eye, which was holding head up. It’s been a habit for her. LPA also reviewed the police report and reported that its unknown if bruise is the result of a crime and this case was being documented due to R1’s injury.

Based on additional document, statements and interviews conducted with staff and administrator and it does not change the previous findings for unsubstantiated for allegation “Resident received unexplained injury while in 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 above allegation is found to be: Unsubstantiated. No deficiencies noted nor citations issued.

A telephonic exit interview was conducted with Executive Director Virginia Garcia. A hard copy of the report was emailed. Staff was instructed to sign the LIC 9099 reports and return to LPA. .

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2021

LIC9099 (FAS) - (06/04)

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