197607655-9-5-2023-28-AS-TVAO-CVTU7V-20230919152033

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607655
Report Date: 09/05/2023
Date Signed: 09/05/2023 12:51:35 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
08/28/2023 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20230828111941

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: 138	DATE:	09/05/2023
		UNANNOUNCED	TIME BEGAN:	08:39 AM
MET WITH:	Alejandra Cevallos - Front desk		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not intervene in resident-on-resident dispute.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation. LPA met with Alejandra Cevallos Front desk and contacted Virginia Garcia administrator via telephone and explained the reason for visit.

The investigation consisted of the following: LPA requested a copy of resident/staff roster. Reviewed file for Resident #1 and #2. Requested copies of face sheet, physician's report, individual service plan, resident appraisal, clinical flex notes for R1 and R2. LPA interviewed residents #1-10 (R1-R10) and staff #1-#5(S1-S5).

The investigation revealed the following: Regarding allegation: Staff did not intervene in resident-on-resident dispute. It is alleged the staff had been aware of the first verbal threat being made by R2 towards R1 about one week ago before the police were called.
(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: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023

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 2

Control Number 28-AS-20230828111941

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: 09/05/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Interviews with residents revealed 8 out of 10 residents stated to not have experience verbal arguments with other residents. Residents stated to feel safe, and that staff will aid right away to a situation like that. 1 out of 10 residents was unable to be interview due to cognitive skills. 1 out of 10 residents stated to have been verbally threaten by another resident and that initially had requested to stay in the room as did not feel the other resident could be harmful. R1 stated staff move R1 to another room the second time R1 mentioned the situation to the staff the same day. Interviews with staff revealed the following: On 7/6/23 R1 moved into room #233 and was alone until roommate returned from the hospital. On 7/27/23 R1 was moved to room #209 per R1’s request as he stated not to be able to sleep due to new roommate. R1 resided in room #209 for some weeks without concerns. About a week before 8/27/23 R1 stated to assistant administrator not being able to sleep due to R2 talking and giving verbal threats at that time R1 was giving the option of moving to another room. However, R1 stated to want to stay in that room. The second time R1 brought up the situation on 8/27/23 in the morning, staff acknowledged R1 and told R1 a different room will be assigned for R1 that night. R1 was moved to room #228 on 8/27/23 before the end of the day. Per document review, R2's physician's report dated 4/22/23 does not note any aggressive or inappropriate behaviors. Both residents have individual services plans in place. Clinical Flex notes noted incident on 8/27/23 which provide the communication between R1 and staff and the determination of moving R1 to a different room the same day before Pasadena police officer arrived at the facility the afternoon of 08/27/23. No history of previous incidents was noted on either residents file. Incident report was not available for review at the time of the visit or submitted to the department within the required 7 days. Although the situation may have happened facility staff address the situation and provided alternative room for R1 upon being presented to the staff.

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.

Exit interview was conducted with Lori Lackey Assistant Administrator and a copy of this report was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2