198602243-9-3-2026-28-AS-WSHO-DXQQC3-20260908120226

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602243
Report Date: 08/25/2026
Date Signed: 09/03/2026 12:17:21 PM

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
08/21/2026 and conducted by Evaluator Mayra Cota

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20260821152956

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: 32	DATE:	08/25/2026
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Rosalie Sandoval, Executive Director		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff did not assist resident with hygiene needs.
Staff interfered with resident's right to have visitors.

INVESTIGATION FINDINGS:

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***This is an amended report. The report has been amended for typographical errors made on the first page (LIC 9099).***
Licensing Program Analyst (LPA), Mayra Cota, conducted unannounced 10-day complaint visit to investigate the above-mentioned allegations. LPA met with Rosalie Sandoval, Executive Director, and the reason for the visit was explained.

The investigation consisted of the following:

LPA obtained copies of staff and resident rosters, toured the common areas of the facility, interviewed Staff 1 – Staff 5 (S1-S5) and Resident 1 – Resident 6 (R1-R6) and reviewed relevant documents for the investigation.

The investigation revealed the following:

***Continues on LIC 9099-C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2026

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 3

Control Number 28-AS-20260821152956

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: 08/25/2026

NARRATIVE

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Regarding: Staff did not assist resident with hygiene needs.

It is alleged that resident’s beard was overgrown and there was dried food in it.

Staff deny the allegation. Interviews with (5) out of (5) staff revealed that staff are assisting residents with their personal hygiene needs. Staff indicated that residents’ beards are groomed by shaving or trimming and food or dried saliva is washed out during the grooming process. Staff indicated that staff monitor resident hair growth and do not let residents’ facial hair become overgrown. Interview with S2 and S3 revealed that R1 receives facial hair grooming by staff weekly. Staff indicated that R1 has a medical condition in which R1 cannot keep a steady gait and therefore, staff cannot use a blade to give R1 a “clean shave.” However, R1 gets a “close trim” with the use of scissors or electric shaver. Staff also indicated that food is not left on R1’s beard after staff help with feeding. Staff clean food particles off R1’s face after each meal is provided by staff. R1 has communication impairments but was able to indicate that their hygiene needs are being met and is not concerned about the length of their beard during interview with LPA. Interview with R2-R6 also revealed that their personal hygiene needs are being met and receive facial hair grooming in a timely manner. During interview with R1, LPA observed their beard to be evenly trimmed and not obstructing their mouth or nose. R1s’ beard was also observed clean. The length of R1’s beard does not pose a hygiene concern. Interviews and observations do not corroborate the allegation that staff do not assist resident with their hygiene needs.

Regarding: Staff interfering with resident's right to have visitors.

It is alleged that staff did not transfer resident to their wheelchair so they can sit in the recreational room with visitors.

Staff deny the allegation. Interviews with (5) out of (5) staff indicated that they do not interfere with residents’ right to have visitors. Staff indicated that the facility’s visitor policy states that residents can have visitors from 9:00 a.m. to 8:00 p.m., daily. Interview with S1 revealed that R1 recently had a visitor who arrived at the facility about 7:15 p.m. on 8/6/2026 and insisted on seeing R1 in the recreational room. S1 stated that the visitor was informed by staff that R1 was already sleeping and that staff would have to wake R1 and transfer R1 to their wheelchair to take them out of their room to see the visitor. S1 stated that staff did not deny visitor from seeing R1; however, visitor was asked to wait for staff who help with R1’s transfers from their bed to their wheelchair to return from their lunch break which was about to end.

***Continues on LIC 9099-C page 2***

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20260821152956

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: 08/25/2026

NARRATIVE

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Interview with S2 revealed that R1’s visitor was not denied from seeing R1 in the recreation room. S2 indicated that they informed the visitor that S2 would bring out R1 once their lunch break was over, which S2 stated was minutes from ending. S2 indicated however, that the visitor became angry and asked why R1 could not be awakened and transferred by someone else on shift. S2 stated that they explained to the visitor that R1’s transfers must be conducted by S2 due to R1’s particular health needs. S2 stated that R1 was eventually assisted by S2 into the recreational room to meet with their visitor without incident. LPA attempted to conduct interview with R1 but R1 was unable to provide information regarding the allegation. Interview with R2 revealed that on 8/6/2026, they witnessed R1’s visitor at around 7:20 p.m. yell at staff after requesting to see R1 for visitation. S2 stated that staff did not deny visitor from seeing R1 and observed staff assisting R1 into the recreation room. Interviews with R2-R6 indicated that staff do not interfere with their visitors from coming to the facility and have no concerns. Review of facility’s House Rules – Standard of Regulations indicate that visitors are welcome and can use the common areas to engage with residents between 9:00 a.m. – 8:00 p.m. Visiting policy also stated that the facility can provide flexibility with prior notice to staff if visitors want to come earlier or later than the indicated times. Interviews and record review do not corroborate the allegation that staff interfere with resident’s right to have visitors.

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: Wei Siew Ho
LICENSING EVALUATOR NAME: Mayra Cota
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2026

LIC9099 (FAS) - (06/04)

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