198602245-9-17-2021-28-AS-CYEE-CDD3KW-20220410181950

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602245
Report Date: 09/17/2021
Date Signed: 09/17/2021 02:25:56 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
09/10/2021 and conducted by Evaluator Alberto Lopez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210910092533

FACILITY NAME:	GARFIELD VILLAS LLC		FACILITY NUMBER:	198602245
ADMINISTRATOR:	SANDOVAL, ROSALIE		FACILITY TYPE:	740
ADDRESS:	1425 N GARFIELD AVE		TELEPHONE:	(626) 398-3261
CITY:	PASADENA	STATE: CA	ZIP CODE:	91104
CAPACITY:	40	CENSUS: 23	DATE:	09/17/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Rosalie Sandoval, administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident went missing from facility.

INVESTIGATION FINDINGS:

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LIcensing Program Analyst (LPAs) Alberto Lopez, Jewel Baptiste, and Nicole Spencer made an unannounced visit to investigate the allegation listed above. LPAs were met by the Administor 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 #1-#4 (R1-R4) and staff from day program (W1). Interview was attempted with S3 but could not be reached. LPAs obtained copies of the staff roster, resident roster, house rules, resident sign out sheets and for R1: hospital discharge papers, physicians reports, incident reports, admissions agreement.

The investigation revealed the following, regarding the allegation that a resident went missing from the facility, the administrator and staff stated that residents are allowed to leave the facility unassisted if physician's report states that they can. ***Narative 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: 09/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

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-20210910092533

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 VILLAS LLC	FACILITY NUMBER: 198602245
	VISIT DATE: 09/17/2021

NARRATIVE

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All staff stated that R1 has history of leaving facility frequently. S1 stated that on 9/9/21, R1 left the facility at 7:00AM and R1 was going to the store. S1 stated that S1 called the day program when they discovered R1 did not return at the usual time and day program staff (W1) stated that R1 was there. At 3 p.m., S1 called the day program again and W1 stated that W1 made an error and R1 was not at the day program. At approximately 7:15 p.m., staff stated that the facility filed a missing persons report with the Pasadena police department since R1 had not come back to the facility. R1 stated that on 09/09/21 R1 forgot to sign out that day and was heading out to go shopping. R1 stated that RI was sent to the hospital because R1 looked disoriented. Per administrator, R1 was admitted to the hospital on 9/12/21 and was discharged from hospital on 9/16/21. Administrator stated that per physician, R1 was admitted due to the hospital because R1 was found unresponsive.

A review of R1's physician's report state that R1 is allowed to leave facility unassisted. Resident sign out sheet showed that R1 did not sign out on 09/09/2021. Incident reports revealed that R1 left facility on 09/09/21 and a missing persons report was filed on the same day. A follow-up incident report stated that UCLA Harbor Medical Center called the facility on 9/13/21 to report that R1 was hospitalized. The discharge papers shows R1 was admitted on 9/12/21 but did not state discharge date. R1-R4 stated that they are allowed to leave the facility unassisted as long as they sign out.

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.

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SUPERVISOR'S NAME: Christine Yee	TELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Alberto Lopez	TELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

LIC9099 (FAS) - (06/04)

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