<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607655
Report Date: 07/29/2024
Date Signed: 07/29/2024 01:54:01 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
06/10/2024 and conducted by Evaluator Mary G Flores
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240610091426
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: 138DATE:
07/29/2024
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Rocio Gonzalez - Wellness Director TIME COMPLETED:
02:12 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not meet resident's toileting needs
Staff did not seek medical attention for resident in a timely manner
Facility is in disrepair
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegations. LPA met with Rocio Gonzalez and explained the reason for the visit.

The investigation consisted of the following: On 6/17/24 LPA conducted an initial visit and requested the following documents: staff/resident roster, physician's report, appraisal, functional capability assessment, medication sheet June 2024, emergency information sheet, incident reports from February- June 2024, facility's clinical notes for resident #1(R1). LPA interviewed administrator and assistant administrator. On 7/29/24 LPA interviewed 8 residents and 6 staff, requested copies of individual service plan, and physician's orders. LPA Flores toured 8 randomly chosen residents’ rooms.

The investigation revealed the following: Regarding allegations: Staff did not meet resident's toileting needs, Staff did not seek medical attention for resident in a timely manner, and Facility is in disrepair.
(CONTINUED ON LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
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 3
Control Number 28-AS-20240610091426
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: 07/29/2024
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
It is alleged R1 has been covered “in poop” and “had pants down with a soiled diaper” due to having uncontrollable diarrhea for which staff did not provide anti diarrheal medication, and the toilet and shower were clogged due to R1 placing toilet paper or paper towels.

Interviews conducted with staff revealed R1 returned from skill nursing facility to the facility on 6/3/24. Upon R1’s returned a declined in cognitive development was observed which prevented R1 from communicating own needs. Per staff upon R1’s return, R1 showed unusual behaviors. Such as, needing to use the bathroom outside of the bathroom, seating without cleaning self after using the bathroom in the bed, combative behaviors when staff attempted to assist with hygiene care. Staff noticed R1 had loose stool on the evening of 6/7/24. Care giving supervisor notified Med-techs, who notified the kitchen staff for a diet adjustment, and monitor for diarrhea. Staff stated that when they notice any resident with diarrhea symptoms the following takes place; If the symptoms continue after 24 hours, the physician is either notified for as needed(PRN) medication to be prescribed or if the PRN medication is already prescribed it is provided to the residents. Per staff in R1’s case the diarrhea did not last longer than 24 hours. Staff stated that the toilet was in fact clogged once due to R1 throwing toilet paper or paper towels inside and flushing it. As well as paper towels found in the shower. However, staff responded to cleaning, removing items that could clog the toilet, and fixing the toilet right away. Per staff R1 was redirected, change as needed after each incident, and provided care. Interviews with residents revealed, residents are assisted as needed with medical care, have not observed fault odors around the facility, and their toilets/showers are in good repair.

Document review revealed, R1’s physician’s report dated: 1/7/24 notes resident needs assistance with incontinence care. On 6/3/24 Skill nursing facility notes R1 may be discharge back to assisted living facility. On 6/4/24 R1 had a physician’s house call due to staff concerns of R1’s behaviors. On 6/6/24 a physician order was place for anti-diarrhea medication. On 6/7/24 and 6/8/24 facility’s clinical notes, noted R1 was refusing assistance with changing and behaviors. On 6/10/24, incident report notes R1 was send to the hospital due to aggressive behaviors. June 2024 medication sheet notes R1 was provided one dose of anti-diarrhea medication on 6/7/24 and a dose on 6/8/24. Although R1 may have had diarrhea and behaviors, per interviews conducted and documents reviewed R1 was provided assistance as needed and facility staff communicated with physician regarding R1’s change in condition and medical needs. During the facility’s tour LPA did not observed any toilets or showers clogged or in disrepair.

(CONTINUED ON LIC 9099C)
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240610091426
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: 07/29/2024
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
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 Virginia Garcia - Administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 07/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3