197607655-6-25-2024-28-AS-RORN-D8YPU4-20240910113655

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607655
Report Date: 06/25/2024
Date Signed: 06/25/2024 01:47:42 PM

Unsubstantiated

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
06/20/2024 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240620150052

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: 137	DATE:	06/25/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator Virginia Garcia		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not accept resident back into care following hospitalization.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Jose Villalobos conducted an unannounced complaint investigation visit for the allegation above. LPA met with administrator Virginia Garcia and the purpose of the visit was discussed.

LPA conducted the following: LPA toured the physical plant of the facility, interviewed staff #1-#4 (S1-S4) and Residents #2-#5(R2-R5), LPA collected copies of the staff and resident roster as well as reviewed and collected documents from Resident #1's (R1) file. R1 was unavailable for interview. LPA interviewed R1's responsible party (W1). The investigation revealed the following:

In regards to the allegation "Staff did not accept resident back into care following hospitalization" it is alleged that facility staff refused to accept R1 back to after being discharged from the hospital....

Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024

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-20240620150052

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: 06/25/2024

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

(3) of (3) Staff interviewed denied the allegation. (4) of (4) Residents could not corroborate the allegation. Interviews state that R1 was hospitalized on 5/31/24 after an incident involving an altercation with a roommate causing behavioral outbursts. While R1 was in the hospital, staff communicated to want to reassess R1's current health and mental status when the hospital then discharged R1 to a skilled nursing facility on 6/20/24. Staff interviewed denied ever refusing to take R1 back into the facility. Staff interviewed stated they are currently awaiting discharge from the skilled nursing facility and will be able to take R1 back. There is no set date on discharge from the skilled nursing facility. W1 stated they had not been informed by the facility either verbally or written that R1 would not be able to return to the facility. File review did not show any documentation of R1 being evicted not allowed back to the facility. LPA observed facility to still be holding R1's personal belongings. Based on interviews, files reviewed and observations conducted; 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 conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2