198602243-8-17-2020-28-AS-FFIS-BSU2GC-20200825172256

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602243
Report Date: 07/30/2020
Date Signed: 08/17/2020 05:01:27 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
09/23/2019 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20190923161633

FACILITY NAME:	GARFIELD TERRACE LLC		FACILITY NUMBER:	198602243
ADMINISTRATOR:	SANDOVAL, ROSALIE		FACILITY TYPE:	740
ADDRESS:	1435 N GARFIELD AVE		TELEPHONE:	(626) 398-0527
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY:	60	CENSUS: 39	DATE:	07/30/2020
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Naylet Velazquez, Staff in-charge		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff failed to prevent resident from harming other residents

Residents do not feel safe due to an aggressive resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tao initiated a subsequent complaint visit regarding the investigation in order to deliver finding on 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 Licensee, staff and residents. LPA discussed the purpose of the investigation with Administrator Rosalie Sandoval.

The investigation consisted of, the initial visit which was conducted on 10/3/2019, which include a tour of the physical plant and a health and safety check. On 12/11/2019, a subsequent visit was conducted and LPA interviewed Administrator and Resident #1 through Resident #6. A telephone interview was conducted with Resident #7 on 01/07/20 and with Staff #3 on 07/29/2020. LPA reviewed special incident reports dated 11/13/19, 09/30/19, 07/14/19, 06/01/19, and 05/10/19; Resident #7(R7)’s Needs and Services plan; R7’s Pre-Placement Appraisal; R7’s Resident Appraisal; and R7’s Physician Report.
( Continued in LIC 9099 C, page 2 )

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2020

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-20190923161633

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: GARFIELD TERRACE LLC	FACILITY NUMBER: 198602243
	VISIT DATE: 07/30/2020

NARRATIVE

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Regarding allegation: Staff failed to prevent resident from harming other residents.
The investigation revealed that on 11/13/19, R7 was being verbally aggressive in the dining room with R4 and other residents. Interviews with R1 to R7, indicate R7 exhibits aggressive behaviors in general. Review of R7 facility file indicates that R7 has a history of being aggressive toward others as indicated on R7 physician report dated 01/31/2018 and staff are aware of R7 behaviors. Facility reported R7’s behaviors in incident reports 11/13/19, 09/30/19, 07/14/19, 06/01/19, and 05/10/19. Per the incident report dated 11/13/2019, at breakfast time in the dining room, R7 threw a beverage at R4 which was witnessed by S3 and other residents. Three out of three staffs’ interviews and four out of seven residents’ interviews indicated that facility staff immediately intervened upon knowledge of the incident between R4 and R7. Staff separated R4 and R7 and redirected R7. Per an interview with R4, it revealed that R4 reported that R4 was not injured due to the incident and did not need medical care at the time. R7 denied the allegation and reported R7 did not do anything. Based upon the investigation, it did not appear that staff failed to prevent a resident from harming other residents, as staff intervened immediately upon knowledge of the 11/13/19 incident between R4 and R7 and other residents. Review of incident reports listed above that involving R7, revealed that although R7 exhibits aggressive behaviors while in the facility, staff were present in the facility to assist other residents as needed.

Regarding allegation: Residents do not feel safe due to an aggressive resident.
Based upon interviews with S1 to S3 and review of R7 facility file, the investigation revealed that when R7 is behaving in a manner that can be described as aggressive or rude. Staff at the facility immediately intervene and redirect R7 away from other residents when incidents happen. Two (2) out of seven (7) residents interviewed said they did not feel safe when R7 was present. Five (5) out of seven (7) residents interviewed indicated they feel safe and reported that staff assist residents when residents are having behaviors that may be deemed unsafe. Interviews with three (3) of three (3) staff indicate staff are present in the facility to assist residents as needed.

( Continued in LIC 9099 C, page 3 )

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20190923161633

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: GARFIELD TERRACE LLC	FACILITY NUMBER: 198602243
	VISIT DATE: 07/30/2020

NARRATIVE

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Review of staff training records indicate staff are trained on how to work with agitated residents and how to ensure other residents’ safety. The investigation revealed that staff intervene as needed and in a timely basis when incidents occur in the facility, therefore, the staff ensure a safe environment for residents.

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 held. A copy of the report was provided to Naylet Velazquez, Staff in-charge.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2020

LIC9099 (FAS) - (06/04)

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