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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607655
Report Date: 06/24/2024
Date Signed: 06/24/2024 03:45:37 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
06/21/2024 and conducted by Evaluator Alma Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20240621152618
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: 137DATE:
06/24/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lori LackeyTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff did not prevent resident from harming another resident in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced complaint visit to gather information pertaining to the above-mentioned allegation. LPA met with Assistant Administrator Lori Lackey and explained the reason for the visit.

The investigation consisted of the following: LPA conducted interviews with Assistant Administrator Lori Lackey, Staff 1-4 (S1-4) and Residents 3-10 (R3-10). R1-2 were not interviewed as they were not in the facility at the time of the visit. LPA obtained copies of Staff and Resident Rosters. LPA reviewed R1-2's facility file. LPA collected copies of documents pertinent to the complaint investigation and conducted a facility tour.


(See LIC9099C for continuation)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
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 2
Control Number 28-AS-20240621152618
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: 06/24/2024
NARRATIVE
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Investigation revealed the following: Regarding allegation, Staff did not prevent resident from harming another resident in care, it is alleged that on 06/21/2024 staff at the facility saw R2 twisting R1's arm which resulted in R1 sustaining a fracture and dislocation to their left elbow. Interview with Assistant Administrator revealed that R1 did sustain a fracture and dislocation to their left elbow which was caused by R2. She stated that R2 wanders and constantly touches things but has never hurt anyone. She stated that staff redirect R2 and any other resident when they are wandering. She stated that R1 and R2 are both non verbal and staff (S2) was assisting another resident when the incident happened. Interview conducted with S2 revealed that they were finishing assisting another resident when the incident occurred but they saw when R2 came close to R1, lifted their blanket, grabbed their arm and immediately called out for assistance in redirecting R2. S1 immediately came to redirect R2 but R2 had already walked away and S1 then proceeded to request assistance from S3 to examine R1's arm. S1-3 stated that the incident happened in a matter of seconds and R2 was immediately redirected but that R2 was also unaware of the harm they caused to R1 due to resident being diagnosed with Major Neurocognitive Disorder. 5 out of 5 staff interviewed denied the allegation and stated that there are enough staff on schedule to properly supervise and care for the residents. 8 out of 8 residents interviewed were unable to corroborate the allegation. They stated that they are satisfied with the services, staff protect them from harm and do not have any concerns. LPA reviewed R1-2's Physician's Report for Residential Care Facilities for the Elderly (RCFE) which revealed that R1-2 are diagnosed with Major Neurocognitive Disorder and have conditions and behaviors in relation to that diagnosis. R2 has wandering behavior and R1 is not able to feed self and is nonambulatory.

During the time of the visit, LPA did not observe any altercations between residents and observed that there were enough staff on schedule. LPA additionally observed staff tending to residents and redirecting residents which were exhibiting wandering behavior. LPA reviewed documents and observed that the proper reporting was done by facility staff as well as proper follow up calls made to both involved resident's responsible parties. LPA additionally reviewed Facility Personnel Report (LIC500) which revealed that the facility is properly staffed to oversee and care for the residents in placement. Based on statements gathered from interviews conducted with staff, residents, LPA record review and observations there was not enough supportive evidence to concur with the reported allegation.

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 allegation is UNSUBSTANTIATED.

Exit interview held. A copy of the report was provided to Assistant Administrator Lori Lackey.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Alma GonzalezTELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2