198603383-7-17-2025-28-AS-DSIS-DKCP6S-20250808110249

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603383
Report Date: 07/17/2025
Date Signed: 07/17/2025 03:03:13 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
05/22/2025 and conducted by Evaluator Daniel Konishi

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250522082507

FACILITY NAME:	TERRACES AT VIA VERDE-A MEMORY CARE COMMUNITY, THE		FACILITY NUMBER:	198603383
ADMINISTRATOR:	JAKINI, ROBERT		FACILITY TYPE:	740
ADDRESS:	1155 VIA VERDE		TELEPHONE:	(909) 293-6466
CITY:	SAN DIMAS	STATE: CA	ZIP CODE:	91773
CAPACITY:	60	CENSUS: 43	DATE:	07/17/2025
		UNANNOUNCED	TIME BEGAN:	02:35 PM
MET WITH:	Subishsani Kumar, Executive Director		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Licensee does not provide a safe environment for residents in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Daniel Konishi conducted an subsequent unannounced initial complaint visit at the facility and met with Mark Chism to discuss the purpose for today's visit. The Executive Director, Subishsani Kumar arrived shortly after and LPA explained the purpose of the visit. The purpose of the visit is to investigate the above allegation.

On 05/27/2025, the initial investigation visit was conducted. The investigation consisted of the following:
LPA interviewed the Executive Director, Maintenance Director, Staff #1 (S1) - Staff #7 (S7). LPA also interviewed Resident #3 (R3) – Resident #7 (R7). LPA attempted to interview Resident #1 (R1) and Resident #2 (R2), however, due to the residents’ inability to answer questions, LPA terminated the interviews. LPA obtained copies from R1’s to R2’s file, including the Physician's Report, Identification and Emergency Information LIC 601 form, Pre-placement Appraisal, Admission Agreement, Personal Rights and Internal Incident Reports. LPA also obtained the staff and residents rosters, and the facility’s House Rules. LPA toured the facility with the Maintenance Director.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025

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-20250522082507

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: TERRACES AT VIA VERDE-A MEMORY CARE COMMUNITY, THE	FACILITY NUMBER: 198603383
	VISIT DATE: 07/17/2025

NARRATIVE

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During today's visit, LPA obtained the following documents: staff and client rosters.

Regarding allegation: Licensee does not provide a safe environment for residents in care. it is alleged that a resident is abusing another resident and staff are not addressing the resident’s behavior, which is creating an unsafe environment for residents in care. Six (6) out of nine (9) staff interviewed denied the allegation. Two (2) out of nine staff interviewed corroborated the allegation and stated being concerned about the multiple occurrences of R1’s physical altercations with R3. One (1) out of nine (9) staff interviewed could not confirm nor deny the allegation. However, nine (9) out of nine (9) staff stated that if residents are involved in an altercation, the staff would immediately intervene, separate, and re-direct the residents being involved. Nine (9) out of nine (9) staff stated that there have been no reported injuries from any resident-on-resident physical or verbal altercations. Nine (9) out of nine (9) staff stated that R1 only able to speak a different language which causes R1 to become more agitated and become physically aggressive. However, nine (9) out of nine (9) staff stated that R1’s family does visit daily and also able to help communicate by the phone to provide assistance. Executive Director also stated that they use their cellphone apps to help communicate with R1. Based on record review, R1’s current physician’s report does not have a history of aggressive behavior. However, R1’s Pre-placement appraisal does state mild nervousness or anxiousness. The Executive Director and (2) out of eight (8) staff stated that R1 is adjusting due to recently moving into the facility and that medications taken also take time for R1 to become stable. Executive Director confirmed that in order to ensure safety, R1 and R3 were moved to different rooms on 05/28/2025. Executive Director stated that if resident’s aggressive behavior continues, they would continue to address and work with residents who have aggressive behaviors. Executive Director stated that R1 moved out of the facility on 06/06/2025. Five (5) out of five (5) residents interviewed denied the allegation and stated that they feel safe at the facility. None of the residents interviewed stated being physically or verbally abused by another resident or staff. Based on interviews conducted with facility staff, facility client, witnesses, and record review, there was not enough supportive evidence to concur with the reported allegation.

Based on statements and interviews conducted with staff, clients, review of client files and facility file records, there was not enough supportive evidence to concur with the reported allegation. 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 allegations are UNSUBSTANTIATED.

Exit interview held, and a copy of this report was provided to the Executive Director, Subishsani Kumar.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Daniel Konishi
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 07/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025

LIC9099 (FAS) - (06/04)

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