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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603383
Report Date: 05/30/2025
Date Signed: 05/30/2025 03:48:05 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
03/24/2025 and conducted by Evaluator Bennette Pena
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250324101021
FACILITY NAME:TERRACES AT VIA VERDE-A MEMORY CARE COMMUNITY, THEFACILITY NUMBER:
198603383
ADMINISTRATOR:JAKINI, ROBERTFACILITY TYPE:
740
ADDRESS:1155 VIA VERDETELEPHONE:
(909) 293-6466
CITY:SAN DIMASSTATE: CAZIP CODE:
91773
CAPACITY:60CENSUS: 42DATE:
05/30/2025
UNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH: Subishsani Kumar - Executive Director TIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Staff transported a resident to a different hospital emergency room.
Staff left harmful material accessible to a resident.
Staff did not meet a resident's catheter needs while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bennette Pena conducted an unannounced subsequent visit regarding the allegations listed above. LPA met with Mark Chisum, Maintenance Director and explained the reason for the visit. Shortly after, Subishsani Kumar, Executive Director assisted LPA with the investigation.

The investigation consisted of the following: On 03/24/2025, LPA Pena obtained a copy of the Staff/Resident roster, facility sketch and conducted a tour of facility and common areas. LPA also obtained pertinent files for Resident #1 (R1).
During today's visit, LPA conducted a tour of the facility focusing on the Memory Care unit. LPA obtained staff/resident roster, Resident #1 (R1) files such as: Identification and Emergency Information/Face sheet, Physician's Report, Pre-placement Appraisal, Admission Agreement, Personal Rights, Kaiser after visit summaries, Medication Administration Records (MARs) from July 2024-March 2025 and Incident Reports related to this investigation. Between 10:40am and 1:30 pm, LPA interviewed Staff #1 (S1) - Staff #4 (S4), Resident #1 (R1) - Resident #5 (R5) and telephonically interviewed Staff #5 (S5). ******CONTINUED ON LIC-9099C*****
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
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 4
Control Number 28-AS-20250324101021
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: TERRACES AT VIA VERDE-A MEMORY CARE COMMUNITY, THE
FACILITY NUMBER: 198603383
VISIT DATE: 05/30/2025
NARRATIVE
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The investigation revealed the following:

In regards to the allegation: "Staff transported a resident to a different hospital emergency room." It is alleged that R1 was taken to the hospital on 11/27/2024 where family members waited for 2 hours, but later found out that R1 was moved to a different emergency room after they called the facility several times for confirmation. (3) out of (5) staff remembered an incident where upon leaving the facility, paramedics informed the facility staff that R1 will be taken to Pomona Valley Hospital, which was then communicated to the family. However, the facility did not receive calls from the paramedics nor the hospital regarding the hospital change. (5) staff interviewed indicated that location changes can happen, but it is the responsibility of the paramedics or hospital staff to inform the family/POA or responsible party or facility staff about such changes. (5) residents interviewed had no comments about the allegation as they were unaware of the incident. Based on records reviewed, former Administrator had informed a family member on 12/04/2024 that R1 was meant to be transported to Pomona hospital. However, while en route, R1 was redirected to a different hospital and the facility did not receive this information from the paramedics, hence was not shared to the family member. Therefore, there was insufficient evidence to corroborate with the allegation.

In regards to the allegation: "Staff left harmful material accessible to a resident." It is alleged that a resident had dinner and placed a urine bag on the table while another resident ate nearby. All staff interviewed denied seeing or hearing about this incident. (5) out of (5) staff interviewed stated that they would never allow such a situation to happen and they are committed to maintaining a clean dining environment to ensure safety and prevent contamination. (5) out of (5) residents interviewed cannot corroborate the allegation. All (5) residents stated that they did not witness or hear anything related to the incident. LPA observed the dining area to be clean and no urine bag was seen on the dining table. Therefore, there was insufficient evidence to corroborate with the allegation.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 28-AS-20250324101021
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: TERRACES AT VIA VERDE-A MEMORY CARE COMMUNITY, THE
FACILITY NUMBER: 198603383
VISIT DATE: 05/30/2025
NARRATIVE
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In regards to the allegation: "Staff did not meet a resident's catheter needs while in care." It is alleged that during the week of 01/06/2025, a resident was seen walking barefoot while dragging what appeared to be a urine bag attached to a catheter. All staff interviewed denied seeing or hearing about this incident. Staff interviewed denied knowing about the incident and stated they prioritize resident safety, including protecting catheters. Staff also stated that their job is to assist all residents in the community to ensure they are not at risk of tripping or falling and if they have seen such an incident, that they will assist the resident immediately. (5) out of (5) residents interviewed denied seeing anyone dragging a urine bag. All residents interviewed stated that if they have seen it, they will call someone or a caregiver to help the resident. LPA did not observe any resident walking barefoot with visible urine bags. Therefore, there was insufficient evidence to corroborate with the allegation.

Based on observations, statements and interviews conducted with staff, residents and facility file records, there was not enough supportive evidence to concur with the reported allegations. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.



Exit interview held, and a copy of this report was provided to Subishsani Kumar, Executive Director.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 05/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4