197607655-10-31-2023-28-AS-TVAO-CXBVH3-20231106152629

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607655
Report Date: 10/31/2023
Date Signed: 10/31/2023 02:44:55 PM

Substantiated

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
03/06/2023 and conducted by Evaluator Mary G Flores

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230306144748

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: 129	DATE:	10/31/2023
		UNANNOUNCED	TIME BEGAN:	01:52 PM
MET WITH:	Virginia Garcia - Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident wandered from the facility due to lack of staff supervision.
Resident sustained a fall resulting from lack of staff supervision.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Mary Flores conducted a subsequent complaint investigation visit regarding the above allegations. LPA met with Virginia Garcia and explained the reason for the visit.

The investigation consisted of the following: On 3/14/23 LPAs Flores and Zaragoza conducted an initial complaint investigation visit and requested a copy of the staff and resident roster, interviewed assistant administrator, reviewed Resident #1(R1)'s file and requested the following copies: incident report dated 3/7/23, identification and emergency information sheet, physician's report dated 3/7/23 and 4/28/21, individual service plan, admission agreement, hospital discharge documents dated 3/5/23. In addition, copy of warning report for staff #2(S2). LPA Flores interviewed R1. On 10/31/23 LPA Flores interviewed administrator and staff #3(S3) and S2 over the phone.

(CONTINUED ON LIC 9099C)

Substantiated

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: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

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-20230306144748

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: 10/31/2023

NARRATIVE

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The investigation revealed the following: Regarding allegations: Resident wandered from the facility due to lack of staff supervision and Resident sustained a fall resulting from lack of staff supervision. It is alleged R1 exited the residential care facility unsupervised and subsequently fell 3 blocks north of the location and was later transported to the hospital. Documents reviewed revealed; On 3/5/23 Pasadena Police Department officers responded to a report of an individual who had fallen on the sidewalk, upon responding the individual was identify as R1 and per protocol transported to the emergency room at Huntington Hospital for an evaluation. Incident report dated 3/7/23 notes R1 left the facility on 3/5/23 at 5:16pm and was taken to the hospital due to a fall. Physician’s report dated 2/2/23 notes R1 has dementia and cannot leave the facility unassisted. Hospital discharge dated 3/5/23 notes R1 was evaluated for brain and cervical trauma and was discharge back to the facility on 3/6/23. On 3/6/23, S2 was given a warning with a (3) three-day suspension for “danger of resident going out the front desk door”. LPA attempted to interview R1 however due to cognitive skills was not able to obtain information. Interviews with staff determined the incident did happen and corroborated that R1 fell down upon leaving the facility unassisted. Per S2, forgot to turn switch to lock the front door and did not notice when R1 left the facility. Upon caregivers inquiring S2 reviewed video footage and saw R1 leave the facility, notify other staff and went out looking for R1. S2 noticed people and police officers assisting R1, who was on the floor, and was transported to the hospital.

Based on LPAs interviews which were conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview was conducted with Virginia Garcia and a copy of this report, LIC 9099D, and appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20230306144748

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/31/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/01/2023 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2 Additional Personal Rights of Residents...: a)...residential care facilities ...shall ...: 4)..., supervision,... that meet... and are delivered by staff that are sufficient in..., qualifications, and competency to meet their needs.This requirement is not met as evidence by:	1 2 3 4 5 6 7	Adminsitrator will ensure that all staff are qualify, sufficient in numbers, and competent to perform their duties and will schedule in-service training on prevention of wandering by POC due date 11/1/23. Will provide a copy of in-service with date, duration, and subject by 11/7/23.
	8 9 10 11 12 13 14	Based on interviews and documents reviewed licensee did not ensure R1 left the faciltiy unassisted and R1 obtained a fall while unsupervised which poses an immediate risk to the health, safety, or personal rights of the persons in care.	8 9 10 11 12 13 14
Type A 11/01/2023 Section Cited CCR 87705(k)(8)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia (k) The following...must be met...: (8) Delayed egress devices shall not substitute for trained staff... to meet... supervision needs of all residents and to escort residents who leave the facility. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Adminsitrator will ensure that all staff are qualify, sufficient in numbers, and competent to perform their duties and will schedule in-service training on ensuring egress system is working and escorting residents outside the facility by POC due date 11/1/23. Will provide a copy of in-service with date,
	8 9 10 11 12 13 14	Based on interviews and documents reviewed licensee did not ensure R1 left the facility unassisted through the front door while a staff was at the front desk which poses an immediate risk to the health, safety, or personal rights of the persons in care.	8 9 10 11 12 13 14

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 Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 10/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

LIC9099 (FAS) - (06/04)

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