198602243-7-26-2021-28-AS-CYEE-C7BV9P-20210929161440

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602243
Report Date: 07/26/2021
Date Signed: 07/26/2021 03:22:23 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
07/21/2021 and conducted by Evaluator Elizabeth Irra

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210721105652

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: 33	DATE:	07/26/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Med Aide/Designated Substitute		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Staff did not report resident missing in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Elizabeth Irra conducted the initial 10-day complaint visit to investigate the above allegation. LPA met with the Med Aide/Designated Substitute/S-1 (Facility Administrator on vacation) and discussed the purpose of today's visit.

During today's visit, LPA interviewed the Med Aide/Designated Substitute/S-1 (covering for Facility Administrator-on vacation), R-1 and reviewed R-1's file. LPA obtained relevant documentation.

Refer to LIC 9099C for the contination of this report.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021

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-20210721105652

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: 07/26/2021

NARRATIVE

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Allegation: Staff did not report resident missing in a timely manner. During today's visit, LPA interviewed the Med Aide/Designated Substitute/S-1 (covering for Facility Administrator), R-1 and reviewed R-1's file. Staff interview revealed that on 07/19/2021 at 9AM, R-1 signed-out of the facility for a medical appointment and to have R-1's cell phone repaired. Per staff interview, R-1's was admitted to this facility on 07/15/2021 and per R-1's Physician's Report, R-1 is able to leave the facility unassisted. Per Staff interview, R-1 is independent and was reported missing on 07/20/2021 at approximately 830 AM as R-1 was not answering R-1's cell phone. Per Staff interview, staff was informed on 07/20/2021 at approximately 10 AM (after Missing Person's Report filed) that R-1 was hospitalized as R-1 called 911 and asked to be taken to the hospital as someone in the community had "pushed" R-1. R-1 was discharged from the hospital back to this facility on 07/21/2021. R-1 confirmed the above noted information. There has not been any further incidents. R-1's file review revealed that staff made a Missing Persons Report within 24 hours. Special Incident Reports were also submitted to Community Care Licensing Division-Adult and Senior Care within Title 22 regulations/timelines.

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 conducted. A copy of this report and Appeal Rights were provided to Med Aide/Designated Substitute.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3312
LICENSING EVALUATOR NAME: Elizabeth Irra	TELEPHONE: (323) 981-3979
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2021

LIC9099 (FAS) - (06/04)

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