198603383-8-26-2025-28-AS-RORN-DQKSAF-20260122124217

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603383
Report Date: 08/26/2025
Date Signed: 08/26/2025 03:44:45 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
08/19/2025 and conducted by Evaluator Luis DeLeon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250819141728

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:	08/26/2025
		UNANNOUNCED	TIME BEGAN:	08:57 AM
MET WITH:	Office Manager Courtney Cortez		TIME COMPLETED:	03:55 PM

ALLEGATION(S):

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Staff did not check on residents in a timely manner
Staff inappropriately removed the signal systems from residents’ rooms
Staff are not answering the facility phone

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPA) Luis De Leon conducted an initial unannounced complaint investigation visit for the allegation listed above. LPA met with the Office Manager Courtney Cortez and explained the reason for the visit. Executive Director Subashsani Kumar joined the visit sometime after.

The investigation consisted of the following: On today’s visit, LPA De Leon toured the physical plant, random rooms in the first and second floor, and common areas with Environmental Service Director Mark Chisum. LPA obtained staff/resident roster, Resident #1 (R1) files such as: Identification and Emergency Information/Face sheet, Physician's Report, Pre-placement Appraisal, and Admission Agreement.

CONTINUED ON LIC-9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Luis DeLeon
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025

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-20250819141728

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: 08/26/2025

NARRATIVE

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Regarding allegation: Staff did not check on residents in a timely manner
It is alleged that staff did not ensure resident’s well-being when resident had fallen to the ground. Staff did not respond in a timely manner to aid residents, instead another resident provided assistance to a resident who had fallen. The investigation reveals the following: Residents interviews revealed that four (4) out six (6) stated that they have not experienced any issues with staff responding in a timely manner. The remaining two residents were unable to respond to LPA’s question. R1 stated that R1 has used the bathroom call button and staff has responded to provide assistance. LPA interviewed R1, who stated that there was one instance where R1 had fallen in R1’s bathroom. R1 yelled out for assistance since the call button was out of R1’s reach, however, staff managed to hear R1’s calls for assistance and provided R1 with assistance. Staff interviews revealed that six (6) out of six (6) staff denied not responding to residents’ calls in a timely manner. LPA observed that during facility activities staff were providing assistance to residents in the common area. LPA tested call buttons in two random residents’ rooms, and the response time was less than five (5) minutes. Staff stated that wellness checks are done every two hours, but if residents have special needs, wellness checks are done more frequently. Based upon the investigation, client and staff interviews, and LPA observations, there was insufficient evidence to corroborate the allegation.

Regarding allegation: Staff inappropriately removed the signal systems from residents’ rooms. It is alleged that the signal system pull cords have been removed from residents’ rooms and bathrooms and that residents may not be able to summon staff for assistance when needed. The investigation reveals the following: The signal system was replaced in May/June; however, the new system was operational on the same day that the previous signal system was removed. There was no downtime experienced at the facility during installation and replacement of signal system. Residents’ interviews revealed that three (3) out of six (6) residents stated that they have not needed to use the call button to summon staff for assistance. R1 stated that R1 has used the bathroom call button and staff has responded to provide assistance. R1 stated that there was one instance where R1 had fallen in R1’s bathroom. R1 yelled out for assistance since the call button was out of R1’s reach, however, staff managed to hear R1 calls for assistance and provided R1 with assistance. Two (2) out of six (6) residents were not able to understand questions about the call system. LPA tested the call system on each floor and staff responded in a timely manner, in less than five (5) minutes. Staff interviews revealed that six (6) out of six (6) staff denied not responding to residents’ calls when the signal system button is pressed.

CONTINUED ON LIC-9099C

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Luis DeLeon
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250819141728

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: 08/26/2025

NARRATIVE

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LPA observed signal system application on each caregiver mobile phone. The caregiver was able to reset call alert only when the caregiver was physically in the room and press the same call button where the alert was activated. Executive Director Kumar explained that all managers have access to mobile signal system alerts and if a caregiver does not respond in a timely manner, the managers will contact the caregiver directly to respond to the signal system call even after business hours. Based upon the investigation, client and staff interviews, and LPA observations, there was insufficient evidence to corroborate the allegation.

Regarding allegations: Staff are not answering the facility phone. It is alleged that the facility is not answering the facility phone. The investigation revealed the following: During business hours, the facility has a receptionist at the front desk answering incoming phone calls. Staff stated that managers will answer phones if the receptionist steps away from the front desk. For after-hour shifts, the main phone line is transferred to night shift MedTech who is responsible for answering the phone. Executive Director Kumar explained that if the main phone line is busy, residents’ families or responsible party may call the facility’s nurse phone line that is available 24x7. In addition, the facility has provided families and/or residents responsible parties with phone numbers of all managers. R1’s trustee confirmed that the trustee had the managers’ phone numbers. Residents interviewed revealed that four (4) out of six (6) residents do not receive phone calls since they don’t have anyone that would call residents. Two (2) out of six (6) residents stated that family prefers to visit them. Staff interviews revealed that six (6) out of six (6) staff denied not answering phone calls. MedTech confirmed that phone calls are transferred to MedTech mobile phone. Staff stated that phone calls may not be answered if the line is busy with another call. However, staff stated that it is unusual to receive telephone calls at night. During the visit, LPA observed that telephone calls were being answered by receptionist. Based upon the investigation, client and staff interviews, and LPA observations, there was insufficient evidence to corroborate the allegation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Exit interview was held with Executive Director Subashsani Kumar. A copy of the report was provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Luis DeLeon
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025

LIC9099 (FAS) - (06/04)

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