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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602243
Report Date: 10/19/2022
Date Signed: 10/19/2022 10:56:46 AM

Unsubstantiated


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
10/05/2022 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221005084357
FACILITY NAME:GARFIELD TERRACE LLCFACILITY NUMBER:
198602243
ADMINISTRATOR:SANDOVAL, ROSALIEFACILITY TYPE:
740
ADDRESS:1435 N GARFIELD AVETELEPHONE:
(626) 398-0527
CITY:PASADENASTATE: CAZIP CODE:
91104
CAPACITY:60CENSUS: 28DATE:
10/19/2022
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator, Rosalie SandovalTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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The facility is not following Covid-19 guidelines.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent complaint visit to investigate further and deliver the findings to the above allegation. Upon arrival, LPA met with S2 who conducted the Covid screening test before allowing LPA in. LPA met with the Administrator shortly thereafter and explained the purpose of today's visit.

During the initial visit on 10/11/2022, LPA obtained a copy of the Staff/Resident roster, Staff’s covid-19 test results for 9/20/2022 and the City of Pasadena return to work authorization for S2. LPA also interviewed Staff #1 (S1) through Staff # 6 (S6), requested copies of the Staff sign in sheet and updated staff roster for Sep. 2022.

During today's visit, LPA obtained a copy of the employee sign in/out sheet (9/16/2022- 9/30/2022), S2’s timecard (9/17/2022-9/29/2022), Staff roster/schedule (Sep-Oct 2022). LPA re-interviewed S2, interviewed Staff #7 (S7) by phone and attempted to interview Staff # 8 (S8). LPA called S8 twice (10/17 @ 1:14pm and 10/18 @ 10:28am) and left voicemail messages requesting a call back, but no response. LPA interviewed Residents #1-#4 (R1-4) whose rooms are located near the office.
******CONTINUED ON LIC 9099-C*****
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
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-20221005084357
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: GARFIELD TERRACE LLC
FACILITY NUMBER: 198602243
VISIT DATE: 10/19/2022
NARRATIVE
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Regarding allegation: The facility is not following Covid-19 guidelines. It was alleged by W1 that S2 was tested covid positive on 9/20/2022 and did not come to work from 9/20/2022 through 9/23/2022. W1 indicated that S1 reportedly called S2 back to work on 9/24/2022 and confirmed that S2 was present in the facility for testing on 9/26/2022. LPA interviewed S1 who denied the allegation. S1 stated that S2 did not return to work until 9/28/2022. S1 stated that she is always in communication with Pasadena Public Health Dept. and has been following everything they ask for. S1 indicated that she is aware of PPHD’s back to work regulation for employees in the facility who have been tested positive. S1 provided LPA the time sheet, sign in/out sheet and covid-19 test results for S2. During the interview with S2 over the phone (10/10/2022), she stated that she went home to isolate as soon as she found out that she was covid positive. S2 stated that she went back to the facility for covid testing only on 9/26/2022 but stayed in the car to test. S2 also stated that she submitted her negative test result which was released on 9/27/2022 to Pasadena PHD to get her back to work authorization. S2 stated that she went back to work on 9/28/2022. LPA’s interviews with S3-8 revealed that they were either off-duty or could not remember if they have seen S2 on either 9/24/2022 and/or 9/26/2022. LPA’s interviews with Residents – R1-4 revealed that they are not sure or cannot remember if they have seen S2 on 9/24/2022 and/or 9/26/2022, therefore were unable to corroborate the allegation. None of the interviews conducted can confirm that S2 returned to work on 9/24/2022 and/or 9/26/2022. The documents and records reviewed by LPA indicated that S2 was out of the office and did not return to work until 9/28/2022.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.



Exit interview held and a copy of the report was provided to the Administrator, Rosalie Sandoval.
SUPERVISOR'S NAME: David SicairosTELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Bennette PenaTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2