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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603383
Report Date: 02/13/2026
Date Signed: 02/13/2026 12:45:42 PM

Substantiated


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
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: 47DATE:
02/13/2026
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Subashsani Kumar - Executive DirectorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff did not address a resident's change in medical condition.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Bennette Pena conducted a subsequent complaint visit regarding the allegations listed above. LPA met with Subashsani Kumar, Executive Director and explained the reason for the visit.

The investigation consisted of the following: On 03/24/2025, LPA Pena obtained a copy of the Staff/Resident rosters, facility sketch and conducted a tour of facility and common areas. LPA also obtained pertinent files for Resident #1 (R1).

On 05/30/2025, LPA conducted a tour of the facility focusing on the Memory Care unit, obtained staff/resident roster, additional facility files and Resident #1 (R1) files. LPA also interviewed Staff #1 (S1) - Staff #4 (S4), Resident #1 (R1) - Resident #5 (R5) and telephonically interviewed Staff #5 (S5).

During today's visit, LPA obtained a copy of the Staff/Resident rosters and delivered findings.
******CONTINUED ON LIC-9099C*****
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2026
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 3
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
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: 02/13/2026
NARRATIVE
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Allegation: “Staff did not address a resident's change in medical condition.” It is alleged that facility staff did not report R1’s change in condition. Interviews conducted by Investigator Hector revealed that R1's cognitive and behavioral responses, which would become more intense at night, had gotten worse. Additionally, R1 had (6) unwitnessed falls, (4) of which resulted in hospitalizations. However, the only change the facility staff made to R1's supervision was to increase their monitoring of R1. (1) of the staff interviewed confirmed that R1 needed a higher level of care. The current facility administrator was unable to provide any documentation from the previous administration's reappraisal of R1, except for a documented statement that R1’s “Assessment will be updated.” The failure of the staff to address and document R1’s change in medical condition corroborates this allegation.

Based on statements and interviews conducted, as well as reviewed files and documentation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Deficiency cited on the attached LIC 9099D. An exit interview was conducted, and a copy of this report was provided to Subashsani Kumar, Executive Director along with the Appeals Rights.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
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
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/20/2026
Section Cited
CCR
87463(b)(1)
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87463 Reappraisals.(b)The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. (1) Significant changes in condition, as defined in Section 87101,....
This requirement is not met as evidenced by:
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Administrator/Licensee to ensure to document and update reappraisals of residents for changes in their physical, medical, mental and social condition.
Administrator will send a signed self certification that they read, reviewed and understood Title 22 Regs. 87463 and send it to LPA/CCL by POC due date.
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Based on interviews and record reviews, the licensee did not comply with the section cited above in which the staff failed to address and document R1’s change in medical condition which poses a potential health, safety or personal rights risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Bennette Pena
LICENSING EVALUATOR SIGNATURE:

DATE: 02/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/13/2026
LIC9099 (FAS) - (06/04)
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