198602243-4-6-2021-28-AS-MVAO-BZZTAP-20210412143351

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602243
Report Date: 04/05/2021
Date Signed: 04/06/2021 12:38:10 PM

Substantiated

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
09/02/2020 and conducted by Evaluator Christine Wong

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200902122350

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: 37	DATE:	04/05/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Rosalie Sandoval		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Facility staff do not keep the facility clean

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Wong conducted a subsequent complaint investigation for the allegation 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 Administrator Rosalie Sandoval.

The investigation consisted of the following: On 09/09/20, LPA conducted the initial 10 days complaint and inspected all shower rooms in the facility (North, South and West shower room) and bathrooms in Room#14, #24, #25, #26, #27 and #33. LPA also interviewed five (5) residents on 09/10/20 and two (2) staff on 09/24/20.

The investigation revealed of the following: “Facility staff do not keep the facility clean.” LPA interviewed five (5) residents and reported the overall of the facility is clean. Residents reported they did not see any mold or rusty stain on the shower curtain.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021

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-20200902122350

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: 04/05/2021

NARRATIVE

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LPA interviewed staff and reported residents had complained the shower room was not clean sometimes. Staff stated residents may poop in the shower room sometimes. In addition, LPA also observed the west shower room during the investigation on 09/09/20, there’s some black dirty stain on the bottom of the bathtub curtain from the side left to the right.

Based on interviews conducted and the observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED

California Code of Regulations, Title 22, Division 6 and Chapter 8 was cited. See LIC 9099D.

A telephonic exit interview was conducted with the Administrator Rosalie Sandoval and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20200902122350

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/05/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type B 04/19/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times.	1 2 3 4 5 6 7	Administrator will ensure the facility shall always be clean safe and sanitary and in good repair. Administrator will send the picture of the clean bath tub curtain of the west shower room via fax by 04/19/21 **Administrator sent the picture for the clean bath tub curtain on the same date*
	8 9 10 11 12 13 14	This requirement was not met by evidence of: Based on LPA’s observation on 09/09/2020 at 3:37pm and interviews conducted with staff , the shower room was not clean and there’s some black dirty stain on the bath tub curtain on west shower room.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2021

LIC9099 (FAS) - (06/04)

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