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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607655
Report Date: 05/28/2021
Date Signed: 05/28/2021 05:10:08 PM



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
10/09/2020 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20201009082525
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: 106DATE:
05/28/2021
UNANNOUNCEDTIME BEGAN:
08:49 AM
MET WITH:Lori Lackey - Assistant Administrator
Virginia Garcia - Administrator		TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not ensure facility was free from pests
Residents are not getting meals on time due to lack of staff
INVESTIGATION FINDINGS:
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Licensing Program Analyst(s) (LPAs) Mary Flores and Luis Mora conducted a complaint investigation visit at the facility for the allegations above. LPAs met with Lori Lackey assistant administrator and explained the reason for the visit. Virginia Garcia administrator arrived 30 minutes later.

The investigation consisted of the following: On 10/13/20 LPA Flores conducted telephone interviews with the assistant administrator, and a video call which consisted of a tour of the kitchen, dinning rooms, halls, and rooms #101, 107, 117, 129, 206, 224, 231, 244, 251. The LPA also requested copies of staff/resident roster, pest control receipts, staff schedules, physician's report, medication sheets, needs/care plan, addmission's agreement and physician notes for residents in the rooms above to be emailed. On 5/28/21 LPAs conducted a tour of the facility which consisted of the kitchen, dinning rooms, common areas, and rooms #105,237,244,245, 251,217, 216, 214, 204, 201, interviewed residents #1,(R1),#2(R2),#3(R3),#4(R4),#5(R5),#6(R6),#7(R7),#8(R8),#9(R9),#10(R10), staff #1(S1),#2(S2),#3(S3),#4(S4),#5(S5),#6(S6),#7(S7),#8(S8), and requested staff/resident roster identify bedridden, non-ambulatory, and hospice residents, pest control invoices for 09/2020 to 12/2020, residents' needs and care appraisal, physician's report, caregivers asssigment shift for each shift, and incontinence care sheets. (CONTINUED LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021
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 5
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
10/09/2020 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20201009082525

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: DATE:
05/28/2021
UNANNOUNCEDTIME BEGAN:
08:49 AM
MET WITH:TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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2
3
4
5
6
7
8
9
Facility staff are not providing timely care for resident's higyene needs
INVESTIGATION FINDINGS:
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3
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5
6
7
8
9
10
11
12
13
Licensing Program Analyst(s) (LPAs) Mary Flores and Luis Mora conducted a complaint investigation visit at the facility for the allegations above. LPAs met with Lori Lackey assistant administrator and explained the reason for the visit. Virginia Garcia administrator arrived 30 minutes later.

The investigation consisted of the following: On 10/13/20 LPA Flores conducted telephone interviews with the assistant administrator, and a video call which consisted of a tour of the kitchen, dinning rooms, halls, and rooms #101, 107, 117, 129, 206, 224, 231, 244, 251. The LPA also requested copies of staff/resident roster, pest control receipts, staff schedules, physician's report, medication sheets, needs/care plan, addmission's agreement and physician notes for residents in the rooms above to be emailed. On 5/28/21 LPAs conducted a tour of the facility which consisted of the kitchen, dinning rooms, common areas, and rooms #105,237,244,245, 251,217, 216, 214, 204, 201, nterviewed residents #1,(R1),#2(R2),#3(R3),#4(R4),#5(R5),#6(R6),#7(R7),#8(R8),#9(R9),#10(R10), staff #1(S1),#2(S2),#3(S3),#4(S4),#5(S5),#6(S6),#7(S7),#8(S8), and requested staff/resident roster, pest control invoices for 09/2020 to 12/2020, residents' needs and care appraisal, and physician's report. (CONTINUED LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20201009082525
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: 05/28/2021
NARRATIVE
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Regarding allegation: Facility staff are not providing timely care for resident's hygiene needs. It is alleged resident has a diaper rash, and has ulcers due to the diaper rash and staff not applying diaper rash cream and/or attending to the residents timely. During interviews with 2 out of 10 residents stated to receive assistance with their daily living timely, 5 out of 10 stated to not required assistance with daily living, and 3 out of 10 residents were not able to respond to interview due to cognitive or verbal skills. Interviews with 4 out of 8 staff stated that there is not sufficient caregivers at the facility, however the caregivers prioritize care for the residents incontinence care needs and meals. 2 out of 8 staff are not familiar with residents care and 2 out of 8 staff stated staff have not reported to not be able to meet residents needs and caregivers are provided assistance to provide care to residents. During document review zero (0) out of 10 residents review are under hospice care care and/or have any notes in their files regarding ulcers or diaper rash.

Based on interviews and resident's documents reviewed the preponderance of evidence standard has been met, therefore the above allegation is UNSUBSTANTIATED.

Exit interview was conducted with Lori Lackey assistant administrator and a copy of this report was provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20201009082525
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: 05/28/2021
NARRATIVE
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The investigation revealed the following: Regarding allegations: Staff did not ensure facility was free from pests. It is alleged facility has cockroaches in the rooms, bathrooms and the kitchen and the facility has bed begs. During the tour of the facility LPAs observed kitchen and common areas were free of pest and a cockroach in room #204's shower. During interviews with 6 out 10 residents stated not to have observed cockroaches in their rooms or the facility. 1 out of 10 residents stated that facility does have a problem with keeping facility free of cockroaches and 3 out of 10 residents were not able to answer interview questions due to cognitive or verbal skills. Interviews with 8 out of 8 staff stated to have observed cockroaches in the kitchen, and resident's rooms, and facility is under pest control treatment once a month and 4 out of the 8 staff stated facility was treated for bed bugs. Documents reviewed for pest control invoices for September, October, November, December 2020 noted the kitchen was service for cockroach treatment and invoices for March and April 2021 showed rooms #230,249,251,255,234,232,228,222,211, staff break rooms were treated for cockroaches and staff stated janitor applies heater daily in random rooms for bed bugs.
Based on observation, interviews, and document review conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found SUBSTANTIATED.

Regarding allegation: Residents are not getting meals on time due to lack of staff. It is alleged at night there are 4 staff to 97 residents and residents are not getting meals on time. During interviews with 7 out of 10 residents stated to receive their meals timely and sufficient amount of food. 1 out of the 7 residents stated that there is not sufficient staff at the facility, and 3 out of 10 residents interviews were unable to provide answers due to cognitive or verbal skills. Interviews with 4 out of 8 staff interviewed stated there is not sufficient staff at the facility. Staff stated to be assigned 16 residents on a regular basis and up to 19 residents when other caregivers are out. However, staff prioritize meals and incontinence change for all residents. 2 out of 8 staff stated that there is sufficient staff at the facility and 2 out of 8 are not aware of staffing issues. Based on caregivers schedule reviewed for the week of 5/21/21 to 5/28/21 caregivers were assigned to 13-14 residents on a regular shift and 16-18 residents when other caregivers were out, which was 4 out of 8 days. It should be noted there are 6 residents under hospice, 0 residents that are bedridden, and 23 residents non-ambulatory.

Based on interviews, and document review conducted the preponderance of evidence standard has been met, therefore the above allegation(s) are found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 are being cited on the attached LIC9099D.
Exit interview was conducted with Lori Lackey assistant administrator and a copy of the report, LIC9099D,and appeal rights was provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20201009082525
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/11/2021
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidence by:
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Administrator will ensure that the facility is kept free of cockroaches and bed bugs at all times by certifying in LIC 9098and will provide further pest control services by 6/11/21.
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Based on observation, and document review Licensee did not ensure facility is free of cockroaches as LPA(s) observed cockroach in room #204 and 8 out 8 staff stated to have observed roaches in the facility which poses a potential Health, Safety, and/or Personal rights risk to persons in care.
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Type B
06/11/2021
Section Cited
CCR
87411(a)
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87411 Personnel Requirements-General: a) Facility personnel shall at all times be sufficient in numbers,...In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care .... for the provision of adequate services.
This requirement is not met as evidence by:
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Administrator will ensure to hire sufficient staff or contract staffing agency to provide sufficient staff when current staff call out sick or out, facility will provide copies of new staff hire and caregiver shif schedule for the month of June by 6/11/21.
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Based on interviews and documents reviewed licensee did not ensure there is sufficient staff at the facility to provide assistance with resident care as 1 staff is assigned 16 - 18 residents when a caregiver is out this poses a potential Health, Safety, or Personal Rights risk for persons in care.
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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: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5