197607655-6-18-2021-28-AS-MVAO-C49QLU-20210623121632

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607655
Report Date: 06/17/2021
Date Signed: 06/18/2021 09:52:58 AM

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
12/29/2020 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20201229153910

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: 108	DATE:	06/17/2021
		UNANNOUNCED	TIME BEGAN:	02:54 PM
MET WITH:	Lori Lackey - Assistant Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident(s) have developed pressure injuries while in care.
Staff did not seek medical attention for resident(s) in a timely manner.

INVESTIGATION FINDINGS:

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This is a corrected version of complaint investigation report completed on 5/4/21 regarding the above allegations to include statement regarding findings missing in report dated 5/4/21.

On 5/4/21 Licensing Program Analyst (LPA) Mary Flores conducted a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Lori Lackey, the facility assistant administrator.

The investigation consisted of the following: 0n 1/5/21 LPA Flores conducted a telephone interview with the administrator, and requested copies of staff roster, resident roster- noting residents under hospice/ bedridden/and non-ambulatory, face sheet, physician's report, needs and care plan, hospice documents, home health care notes, caregiver notes, SIR for residents #1,2,3,4,5,6,7,8,9 to be emailed to the LPA. On 4/20/21 LPA conducted a telephone interview with assistant administrator to correct report created on 1/5/21 and requested the following documents; Admissions Agreement, Face Sheet/Identification and Emergency Information LIC601, (Continued on 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

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-20201229153910

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: 06/17/2021

NARRATIVE

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Appraisal/Needs and Service Plan, Hospice documents, Home Health Care notes, Caregiver notes, Unusual Incident Reports, for residents #1,#2,#3,#4,#5,#6,#7,#8,#9,#10,#11. In addition the following documents for R10, and R11; Physician's Report. On 4/26/21 LPA conducted a review of hygiene supplies via video call with Assistant Administrator. On 5/3/21 LPA Flores interviewed residents #1,#2,#3,#4,#5,#6,#7,#8,#9,#10, #11,#12,#13,#14 (R1,R2,R3,R4,R5,R6,R7, R8,R9,R10,R11,R12,R13,R14) and staff#1,#2,#3,#4,#5,#6,#7, #8,#9,#10 (S1,S2,S3,S4,S5,S6,S7,S8,S9,S10) and requested staff in services, caregiver shift assignments, and admissions agreement, physician's report, needs and service plan/appraisal, and hospice/home health care.

The investigation revealed the following: Regarding allegations: Resident(s) have developed pressure injuries while in care and Staff did not seek medical attention for resident(s) in a timely manner. It is alleged that there are many residents with pressure ulcers at varying stages that are not being treated. During interviews with residents, 7 out of 14 residents stated not to have had any injuries recently and that facility assist residents with scheduling medical appointments. 7 out of 14 residents were unable to provide an answer due to their physical condition or cognitive skills. LPA was unable to interview R5, and R11, as residents past away prior to date of interview. 7 out of 10 staff interview stated to be able to identify pressure injuries or wounds and described the steps to take if pressure injuries or wounds are notice as follow; notify supervisor of residents' change in condition, facility then contacts either Hospice or Home health care for care, for residents that are not under hospice or home health care, facility contacts Physician to initiate proper care. 4 out of the 10 staff have not seen any residents with injures under their care. Documents review determined that 7 out 16 residents were receiving hospice services, 1 out of 7 Hospice notes reviewed noted care for altered skin <14 and care was being provided by Hospice agency, 4 out of 16 residents' documents reviewed showed residents were receiving services from a Home Health Care provider and 5 out of 16 resident documents reviewed determined residents do not receive Hospice or Home health care services. Caregiver shift assignment for the month of April reviewed showed each caregiver is assigned an average of 13 to 15 residents per day, and on days a caregiver is out, each caregiver is assigned 15 to 17 residents. Facility provided in service training to staff on the following topics and dates: Pressure Prevention on 5/18/20, Rotating Residents every 2 hours on 8/19/20, and Wound Care Prevention on 4/26/21.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegations. (CONTINUED 9099C)

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20201229153910

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: 06/17/2021

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 allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED Exit interview was conducted with Lori Lackey, Assistant Administrator and a copy of the report was email for signature.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2021

LIC9099 (FAS) - (06/04)

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