198603383-12-15-2025-28-AS-DSIS-DQT2NM-20260129163251

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603383
Report Date: 12/15/2025
Date Signed: 12/15/2025 03:54:28 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
02/07/2025 and conducted by Evaluator Tena Herrera

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250207091124

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: 49	DATE:	12/15/2025
		UNANNOUNCED	TIME BEGAN:	09:49 AM
MET WITH:	Subashsani "Suby" Kumar - Executive Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility staff did not dispense medications as prescribed
Resident sustained unexplained injuries in care
Facility staff did not ensure that resident was adequately fed
Facility staff did not ensure that resident had clean linens

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tena Herrera conducted an unannounced subsequent complaint visit to investigate the above allegations. LPA met with Executive Director Suby Kumar and discussed the purpose of the visit.
The investigation consisted of the following:
On 2/10/25 LPA Wesley conducted initial visit, toured facility, Interviewed Administrator, staff, and residents, received copies of facility food menu's, and requested specific documents from Resident (R1) file. Furher investigation needed. During todays visit 12/15/25 LPA Herrera conducted the supsequent visit and obtained copies of the resident/ staff rosters, copy of December 2025 menus, and copies of the following documents from R1's file: MAR, Charting Notes (observations), and weight record. LPA toured facility, inspected food supply,a total of 5 resident rooms were entered and inspected, LPA observed storage with incontinence supplies and linen supply, LPA interviewed 4 staff (S1-S5) and 5 residents (R1-R6), and deleivered findings on the reported allegations. R1 and S1 are no longer affiliated with facility therefore interviews were not conducted with them. (Continued on LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025

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-20250207091124

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: 12/15/2025

NARRATIVE

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The investigation revealed the following:
Allegation: Facility staff did not dispense medications as prescribed.
It is alleged that staff at facility were not dispensing resident’s medications as prescribed and administered PRN to R1 without consulting with responsible party before or after administering the medication. LPA conducted medication review, a total of 5 resident medications were reviewed with no issues observed. LPA reviewed R1’s MAR (Medication Administration Record) and did not observe any issues notations of medication being administered outside of the doctors’ instructions. LPA interviewed 4 staff and each denied the allegation, interviews with S3-S5 revealed that the Medication System that is used is very precise and does not allow medications to administer a medication before the allowed time. Staff also stated that contacting responsible parties is not a requirement when administering PRN unless the resident is not responding well to the medication, in which they will call family/responsible party/doctor and meet with them to create a plan/medication routine that will work best for the resident. LPA interviewed 5 residents and each denied the allegation and stated they do not have issues with the medication and believe medication is being given to them as prescribed.

Allegation: Resident sustained unexplained injuries in care.
It is alleged that R1 had an unwitnessed fall, sustained injuries from the fall and could not provide reasons or details of what happened. LPA reviewed R1’s file and within the Charting Notes (observations) R1 experienced a fall on 1/27/25 where resident was observed on floor near bed at 9pm with redness on right hip area and no major injuries, it is noted that family were contacted about the fall. LPA interviewed 4 staff and each denied the allegation and stated that falls at the facility are always documented and reported to the resident’s family and doctor (hospice if needed). Staff stated that residents are monitored post fall at all times and if the resident is injured, hits their head or complains of pain they call 911 to have the resident accessed. LPA interviewed 5 residents, and each denied the allegation and stated they have not had any unexplained injuries at the facility.

(Continued on LIC9099-C)

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250207091124

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: 12/15/2025

NARRATIVE

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Allegation: Facility staff did not ensure that resident was adequately fed.
It is alleged that R1 was not adequately fed and appeared extremely thin. LPA reviewed R1’s file and observed that there were no major fluctuations in weight from admission to discharge (November 2024-January 2025) with weight beginning at 84.5lbs (admission weight) and ending at 84.1lbs (discharge month weight). LPA interviewed 4 staff and each denied the allegation and stated the residents are being fed well with meals and snacks provided. Staff stated that there is a meal record kept for each residents that will monitor if they have a loss of appetite and when that is noticed the family and doctor are notified. LPA asked Suby for a copy of the meal chart for R1, however, this is a new procedure that began in April 2025, 3 months after R1 was discharged from facility. LPA interviewed 5 residents and each denied the allegation and stated that they like the food and are provided with 3 meals a day and snacks are offered throughout the day. Additionally, LPA reviewed the food menu and food supply and did not see any issues, snacks were being prepared during visit and included ice cream with chocolate syrup, fruit and yogurt, meal served for lunch was a BBQ Chicken Sandwich with Baked Beans and Coleslaw.

Allegation: Facility staff did not ensure that resident had clean linens.
It is alleged that facility staff left R1’s bed soaked in urine. LPA toured facility, a total of 5 resident rooms were entered and LPA observed all rooms to be clean with clean/dry linens, no foul odors were observed and spare clean linens were stored in resident closets along with incontinence supplies. LPA observed a sufficient amount of incontinence care items in the facility storage. LPA interviewed 4 staff and each denied the allegation and stated that when a residents linens are soiled the caregivers immediately strip down the bed and wash the linens, and prepare the residents bed with the spare clean linens. Staff stated that there are weekly linen changes, however, the linens will also be changed on an as needed bases. LPA interviewed 5 residents and each denied the allegation and stated that their rooms and bed are maintained clean and do not have any issues with linens being soiled.

Based on statements and interviews conducted with staff/residents, review of R1's file and facility 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.

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Tena Herrera
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025

LIC9099 (FAS) - (06/04)

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