198602243-4-28-2022-28-AS-MVAO-CFET4B-20220615142341

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602243
Report Date: 04/28/2022
Date Signed: 04/28/2022 05:10:59 PM

Unsubstantiated

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
04/19/2022 and conducted by Evaluator Alberto Lopez

COMPLAINT CONTROL NUMBER: 28-AS-20220419122845

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:	04/28/2022
		UNANNOUNCED	TIME BEGAN:	11:39 AM
MET WITH:	Rosalie SandovaL, Administrator		TIME COMPLETED:	05:11 PM

ALLEGATION(S):

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resident AWOL’d from facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPAs) Alberto Lopez, made an unannounced visit to investigate the allegation listed above. LPA were met by the Administrator Rosalie Sandoval and explained the purpose of today's visit.

The investigation consisted of a tour of the facility and interviews with the administrator, staff #1-#3 (S1-S3), residents #2-#5 (R2-R5). LPAs obtained copies of the staff roster, resident roster, house rules, resident sign out sheets and for R1, hospital discharge papers, physicians reports, admissions agreement, medical assessment/care & service plan. Police report number, medication sheet for April 2022. SIR for 02/12/22, 03/12/22, 03/13/22 and 4/05/2022 and 04/19/22. Initial History and Physical, Physicians statement that resident can leave facility unassisted and electronically signed by Health care provider DATED 4/28/2022 Order is effective back to date of admission of 02/16/22. R1 was hospitalized at the time of visit. At 4:15pm LPA called R1 at hospital and R1 did not pick up the phone in R1 room. 4:19pm LPA called Southern California Hollywood Community Hospital again and staff confirmed R1 at hospital. R1 refused to speak to LPA at the time ask staff to ask LPA to call back. ***Narrative continued on 9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

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-20220419122845

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: 04/28/2022

NARRATIVE

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The investigation revealed the following, regarding the allegation that a resident AWOL’d from facility, the administrator and staff stated that residents can leave the facility unassisted if physician or health professional states that they are able or if facility Administrator assess resident capable of leaving unassisted.

S1 stated that on 04/18/22am R1 signed out at 9:17am, R1 left the facility and stated he was going to Department of social services. S1 stated that S1 waited 24 hours then called police to file a missing person report. Police called facility and they provided facility with an address of where R1 was going to be going after the park. R1 stated to police R1 would return to facility on own. R1 returned to facility on 04/24/2022 and on 04/26/22 was sent to hospital for stomach pain. S1 stated that R1 was drinking and refused to return to facility.

A review of R1's physician's medical assessment states that R1 does not wander. Resident sign out sheet showed that R1 did sign out on 04/18/2022 at 9:30am. Incident reports revealed that R1 left facility on 4/18/202 and a missing person’s report was filed on the next day. R2-R4 stated that they can leave the facility anytime and they sign out to comply with house rules.

S3 stated he was at facility when R1 returned on April 24 at 6:40pm and asked R1 where R1 had been. R1 told S3 that he was in the hospital for 2 days (facility called hospital and hospital denied he was at hospital) and 2 days at a friend’s home on Orange grove address. S3 asked R1 to sign in but refused. S3 asked R1 to bath since his clothes were dirty. S3 stated that all residents can leave the facility when they wish unless there is a physician’s order prohibiting it.

Based upon interviews conducted and records reviewed, the findings indicate although the allegation(s) may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) are Unsubstantiated. An exit interview was conducted with Administrator and a hard copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 04/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022

LIC9099 (FAS) - (06/04)

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