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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602243
Report Date: 11/22/2025
Date Signed: 11/22/2025 09:22:38 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
10/29/2025 and conducted by Evaluator Christian Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20251029154058
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: 29DATE:
11/22/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Andrea Flores Residential AideTIME COMPLETED:
09:35 AM
ALLEGATION(S):
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Staff do not ensure that resident has clean bedding
Staff interacts with residents in an inappropriate manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Residential Aide Andrea Flores who assisted with today’s visit.

The investigation consisted of the following: During the initial visit conducted on 11/06/2025, LPA obtained copies of the following documents: Staff roster, resident roster, and conducted a room check for R1.On 11/18/2025, LPA’s Gutierrez and Castro interviewed Administrator, staff 1- staff 5 (S1-S5) resident 1 (R1) by telephone, residents 2-residents 7 (R2-R7) and room checks. LPA obtained copies of the following documents: R1’s physicians reports, identification information (LIC 601), appraisal needs and service, facility resident council meeting notes, Orkin Pest Control, and Squash Pest Control invoices. During today’s visit LPA Gutierrez delivered findings.

SEE LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2025
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
Control Number 28-AS-20251029154058
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GARFIELD TERRACE LLC
FACILITY NUMBER: 198602243
VISIT DATE: 11/22/2025
NARRATIVE
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In regard to the allegation” Staff do not ensure that resident has clean bedding”, It is alleged that R1’s bedding had urine on it and staff refused to change bedding. During interview with Administrator, and staff six (6) out of six (6) stated that bedding is cleaned once a week or as needed. During initial visit on 11/06/2025 LPA observed R1’s bedding stained with urine. R1 stated to Administrator that he/she had asked the night before for linen to be changed and Administrator stated staff would be there today at 3:00 PM to change it. During visit on 11/18/2025 LPA observed room 9 and room 17 to have urine-stained bedding. Interviews with residents, four (4) out of seven (7) stated that they have had urine-stained bedding or witnessed other residents with soiled linen. R1 stated that they are supposed to change bedding weekly but get too busy to do it. R7 stated one time they had an accident and when staff was asked to change sheets, they stated that it’s not my job wait till another staff gets here, forcing S7 to wait till the next day.

In regard to the allegation” Staff interacts with residents in an inappropriate manner”, It is alleged that staff (S6) refuses food and or snacks and is rude to residents. During interview with Administrator, and staff six (6) out of six (6) stated that they have never interacted with a resident in an inappropriate manner nor ever witnessed another staff treating residents inappropriately. Administrator stated that a complaint was made about S6, and he/she was spoken to but later that day witnessed the resident shaking hands with that staff. During interviews with residents five (5) out of seven (7) stated that S6 denies them food by telling them kitchen is closed. R1 stated that S6 is rude and calls him/her names. R7 stated that S6 tosses plates at them when serving food, is rude, and has denied them food.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and a copy of this report was given to Andrea Flores.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
10/29/2025 and conducted by Evaluator Christian Gutierrez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20251029154058

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: 29DATE:
11/22/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Andrea Flores Residential AideTIME COMPLETED:
09:35 AM
ALLEGATION(S):
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3
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5
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9
Staff speaks inappropriately to resident
Staff do not ensure the facility is free of insects
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christian Gutierrez conducted a subsequent complain visit in regard to the allegations listed above. LPA met with Caregiver who assisted with today’s visit.

The investigation consisted of the following: During the initial visit conducted on 11/06/2025, LPA obtained copies of the following documents: Staff roster, resident roster, and conducted a room check for R1.On 11/18/2025, LPA’s Gutierrez and Castro interviewed Administrator, staff 1- staff 5 (S1-S5) resident 1 (R1) by telephone, residents 2-residents 7 (R2-R7) and room checks for six residents. LPA obtained copies of the following documents: R1’s physicians reports, identification information (LIC 601), appraisal needs and service, facility resident council meeting notes, Orkin Pest Control, and Squash Pest Control invoices. During today’s visit LPA Gutierrez delivered findings.

SEE LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2025
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-20251029154058
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GARFIELD TERRACE LLC
FACILITY NUMBER: 198602243
VISIT DATE: 11/22/2025
NARRATIVE
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In regard to the allegation” Staff speaks inappropriately to resident”, It is alleged that S6 calls residents out of name. During interview with Administrator, and staff six (6) out of six (6) stated that staff has never called a resident out of their name. S6 stated that with difficult residents another staff will usually assist so they can take care of residents together. During Interviews with residents five (5) out of seven (7) stated that staff has called them out of their name. R1 stated that staff is rude and calls me names.

In regard to the allegation” Staff do not ensure the facility is free of insects”, It is alleged that facility has bugs in the bedrooms. During interview with Administrator, and staff six (6) out of six (6) stated in the past they have had issues with bugs but have been spraying the facility and working with Orkin. Staff stated that the insects’ problems have gotten better. During interviews with residents five (5) out of seven (7) stated that they have seen bugs in the past but that they are taking care of the problem by spaying the rooms. LPA obtained copies of invoices from Orkin pest control that showed monthly services are being conducted however Administrator stated something else was needed to treat the bug issues and has set up service with a new provider Squash Pest Control

Although the allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Rosalie Sandoval, Executive Director and a copy of this report was provided.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20251029154058
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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: 11/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
11/23/2025
Section Cited
CCR
87303(3)(C)
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87307 Personal Accommodations and Services (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of:
(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited.

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Administrator will insure bedding is free from urine stains and have staff check residents bedding more often. Administrator will go over section 87307 training with staff and submit to LPA by POC due date.
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Based on observations and interviews licensee did not ensure, residents were provided clean linen free of urine stains which poses an immediate risk to the health, safety, and personal rights of the persons in care.


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Type A
11/23/2025
Section Cited
CCR
87468.1(a)(3)
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87468.1 Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination.




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Administrator will give training to all staff on personal rights of the residnets 87468.1(a)(3) with all staff and send log to LPA by PO due date.
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Based on observations and interviews licensee did not ensure, residents were being free from intimidation, ,or other actions of a punitive nature by staff which poses an immediate risk to the health, safety, and personal rights of the 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.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Christian Gutierrez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5