198602243-5-8-2026-28-AS-FFIS-DTZS5Z-20260512133512

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602243
Report Date: 05/08/2026
Date Signed: 05/08/2026 10:21:00 AM

Unsubstantiated

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
11/14/2025 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20251114145415

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:	DATE:	05/08/2026
		UNANNOUNCED	TIME BEGAN:	08:13 AM
MET WITH:	Rosalie Sandoval		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff did not ensure that the facility is kept free of bed bugs.
Staff did not provide shower assistance to resident in care.
Staff left resident in care in a soiled diaper for an extended period of time.
Staff did not provide feeding assistance to resident in care in a timely manner.
Staff did not safeguard resident's personal items.
Staff enter residents' room without permission.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit to deliver a superseded report. The reason for the visit was to add the allegation “Staff enter residents' room without permission.” On 03/03/3036, LPA Kimberly Ramirez conducted an unannounced subsequent complaint investigation and delivered findings. On 11/18/2025, LPA Ramirez conducted an initial complaint investigation visit and a need further investigation was documented. During today’s visit, LPA Ramirez was greeted by Administrator Rosalie Sandoval and explained the purpose of the visit.
The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff Roster (LIC 500), Staff#1-4 (R1-R4) interviews, Resident#1-11 (R1-R11) interviews, copy of pest control service agreement and technician notes, copies of R5's: physician's report, Appraisal/Needs and services plan, client/resident personal property and valuables log (LIC 621), copies of R2's : Hospice care plan, physician's report, Appraisal/Needs and services plan, copy of R6's physician's report, copy of facility Resident Theft and loss record, copy of facility plan of operation, and physical plant tour.SEE 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026

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-20251114145415

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: 05/08/2026

NARRATIVE

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The investigation revealed the following: regarding the allegation “Staff did not ensure that the facility is kept free of bed bugs.” It is alleged the facility is not kept free from bed bugs. Two (2) out of the eleven (11) residents interviewed corroborated this allegation. Four (4) out of the four (4) staff interviewed denied this allegation. During record review, LPA observed a pest control service agreement effective from 10/21/2025 through 10/21/2026. This agreement revealed that pest control services will be provided once a month. Service report dated 11/2025, and 12/2025 revealed that no live insects were witnessed in any rooms during treatment. On 11/18/2025, LPA Ramirez inspected eight (8) resident rooms at random and did not observe insects in these rooms. 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.

“Staff did not provide shower assistance to resident in care.” It is alleged the staff are providing R6 with shower assistance. Eleven (11) out of the eleven (11) residents interviewed denied this allegation. Four (4) out of the four (4) staff interviewed denied this allegation. Interview with R6 revealed that staff does assist them with bathing at R6’s request and when R6 chooses to bathe. Staff interviews revealed that all residents have a shower schedule and staff maintain a shower log. Staff revealed that whenever a resident refuses to shower, staff will document the refusal and try at a later time to encourage the resident to shower. 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.

“Staff left resident in care in a soiled diaper for an extended period of time.” It is alleged that staff left a resident soiled in a diaper for an extended period of time. Three (3) out of eleven (11) residents interviewed corroborated this allegation. Four (4) out of the four (4) staff interviewed denied this allegation. During resident interviews, LPA observed residents to be groomed and did not observe residents to be malodorous. During resident rooms tour, LPA observed unsoiled disposable underpads on top of resident mattresses for residents with incontinence care. LPA observed extra adult diaper supply in staff office. 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.

SEE 9099-C

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20251114145415

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: 05/08/2026

NARRATIVE

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“Staff did not provide feeding assistance to resident in care in a timely manner.” It is alleged that staff do not provide R2 with feeding assistance. Eleven (11) out of eleven (11) residents interviewed denied this allegation. Four (4) out of the four (4) staff interviewed denied this allegation. Interview with R2 revealed that staff do provide them with feeding assistance. Review of R2’s physician report revealed that R2 is able to self-feed themself. 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.

“Staff did not safeguard resident's personal items.” It is alleged that staff did not safeguard R5’s personal belongings. One (1) out of eleven (11) residents interviewed corroborated this allegation. Four (4) out of the four (4) staff interviewed denied this allegation. Interview with R5 revealed that several articles of clothing and food items went missing. R5 revealed they told staff about the missing clothing and food, but staff did nothing to locate the items. Staff interviews revealed that R5 has a history of storing expired fresh food items in their room which causes insects and odors in R5’s room. Staff interviews and records reviewed revealed that on 01/13/2023, R5 and the facility signed an agreement in which R5 agreed to allow staff to enter R5’s rooms to discard rotted food. Staff interviews revealed that they have never discarded R5’s clothing or any valuables. LPA observed documentation dated 10/27/2025, which revealed staff threw away rotted cheese in R5’s room. Review of R5’s client/resident personal property and valuables log (LIC 621) revealed several personal belongings of R5’s logged with dates from 2018 through 2024. 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.

“Staff enter residents' room without permission.” Seven (7) out of eleven (11) residents interviewed denied this allegation. Residents#2, 5, 6 and 7 (R2, R5, R6, R7) were unavailable to be interviewed during LPA’s visit. Four (4) out of the four (4) staff interviewed denied this allegation. Staff interviews revealed that staff always knock before entering any resident rooms. During facility tour, LPA observed several resident doors to be wide open and LPA observed facility staff announcing their presence at the foot of the door, before being allowed entry by residents. 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.

No deficiencies were cited. Exit interview was conducted. A copy of this report was provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026

LIC9099 (FAS) - (06/04)

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