197607655-11-13-2024-28-AS-TVAO-DB9P3K-20241122095740

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607655
Report Date: 11/13/2024
Date Signed: 11/13/2024 03:27:01 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
06/04/2024 and conducted by Evaluator Mary G Flores

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240604123448

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: 141	DATE:	11/13/2024
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Virginia Garcia - Administrator		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff did not prevent resident from being physically abused by another resident while in care.

INVESTIGATION FINDINGS:

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

The investigation consisted of the following: On 6/5/24 LPA Flores conducted a health and safety check at the facility and requested pertaining documents to resident #1-#2(R1-R2). On 6/4/24 complaint was referred to the Investigation Bureau department and it was assigned to Sonia Sandoval for investigation. On 11/13/24 LPA Flores delivered findings for above allegation.

The investigation revealed the following: Regarding allegation: Staff did not prevent resident from being physically abused by another resident while in care. It is alleged two residents had been involved in an altercation at the facility, and R1 sustained an abrasion to upper lip as a result.
(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: 11/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

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-20240604123448

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: 11/13/2024

NARRATIVE

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On 5/30/24, R1 was found in his bed with a cut to the lip after staff heard R1 calling out for help, roommate R2 was found in the room seating in own bed. Interviews conducted with staff revealed staff #2(S2) heard R1 yelling from the room and S2 responded. Upon S2 entering the room R1 stated “R2 hit me, for no reason.” Assistant administrator stated to have had knowledge of R2’s aggressive behaviors and the roommate arrangement was done on 5/29/24. Assistant administrator stated to been made aware by a staff that during R2’s stayed at a different licensed facility, R2 had assaulted a roommate. Staff stated R2 had demonstrated a few aggressive incidents with other residents. Interviews were attempted with R1 and R2. However, due to cognitive skills both residents were unable to provide information about the incident. On 6/5/24 LPA Flores conducted a health and safety and observed R1 had bruising in the left side of the face from the cheekbone to the chin.
Documents reviewed revealed: On 6/3/24 Police officers responded to the facility on a report for a battery investigation, due to R1 have bruising to the mouth and jawline, an abrasion to the upper lip and a broken prosthetic eye. On 6/4/24 facility submitted an incident report to the department to report R1 was found in the room with a cut to the lip. Assisted Living Waiver (ALW) individual plan - dated: 12/5/23 notes R2 could be verbally aggressive and is frequently agitated with poor judgement. R2’s appraisal - dated: 5/23/24 notes R2 has poor judgment. On 5/14/24 R2’s physician’s order was created for an evaluation of altered mental state. Clinical flex notes revealed, on 4/19/24 R2 had punch another resident in the arm. Clinical flex notes dated 5/24 and 5/25/24, note R2 had 2 episodes of aggressive behavior. Due to interviews conducted and documents reviewed facility staff failed to properly assess R2 and prevent R1’s injury after observing and gaining knowledge of R2’s history of behaviors. Therefore, this allegation is substantiated.

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

***An immediate Civil Penalty of $500.00 is being issued today, due to Resident #1 obtaining an injury by Resident #2 while in care. Refer to LIC 421IM***

The issuance of a civil penalty is being considered based on Health & Safety Code 1569.49 (f); if the department determines the injury of the resident is due to neglect.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240604123448

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: 11/13/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 11/14/2024 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2...Personal Rights...: (a)...shall have all...: (4) To care, supervision, and services that meet their individual needs ... that are sufficient..., qualifications, and competency to meet their needs. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator will update needs and care plan to reflect supervision, care, needs, behaviors, and room status for R2 and will submit a copy to the department by POC due date 11/14/24.
	8 9 10 11 12 13 14	Based on observations, interviews, and documents reviewed licensee failed to ensure R1 was injured by R2 while in care which poses an immediate health, safety, or personal rights risk to the persons in care. Immediate $500 civil penalty is being assess	8 9 10 11 12 13 14	An additional $500 civil penalty was assessed due to repeated violation noted on 4/23/24. Civil penalties were assess for a total of $1000.
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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: 11/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024

LIC9099 (FAS) - (06/04)

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