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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202402
Report Date: 12/13/2022
Date Signed: 12/13/2022 11:32:33 AM

Document Has Been Signed on 12/13/2022 11:32 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:JASMINE GARDEN RESIDENTIAL CAREFACILITY NUMBER:
157202402
ADMINISTRATOR:BARCELONA, MARC OR NELIAFACILITY TYPE:
740
ADDRESS:14016 TOLUCA DRIVETELEPHONE:
(661) 410-8297
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY: 6CENSUS: 4DATE:
12/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator, Marc BarcelonaTIME COMPLETED:
11:47 AM
NARRATIVE
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On 12/13/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection - infection control. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Administrator, Marc Barcelona.
LPA conducted a facility tour with Administrator. COVID-19 guidelines are in place. Facility appeared cleaned. Hand sanitizer was readily available to residents and visitors at facility entrance. Social distancing is maintained in the common and dining areas. Bathrooms have trash cans with lids. Hand washing posters were observed by the bathroom sink. Bedrooms are single occupant. LPA observed the bed in room 3 to be blocking the fire exit.

LPA checked residents’ locked medications and observed a 30-day supply. Food supply was checked and there appeared to be an adequate supply. Cleaning and PPE supplies were checked. Facility staff was observed with mask on. Resident’s files had updated emergency contact information.

LPA is requesting the following documents be submitted to the Fresno CCL office by 01/03/2023: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond

A deficiency is being issued in accordance to California Code of Regulations, Title 22, Division 6 for fire clearance.

Exit interview conducted and a plan of correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Marc Barcelona, whose signature on this form confirms receipt of this document.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/13/2022 11:32 AM - It Cannot Be Edited


Created By: Alexandria Walton On 12/13/2022 at 11:04 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: JASMINE GARDEN RESIDENTIAL CARE
FACILITY NUMBER: 157202402

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
87202 Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when the bed in room 3 was blocking the fire exit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/14/2022
Plan of Correction
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Licensee repositioned the bed in Room 3 to clear the area in front of the exit door. POC cleared during inspection.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022


LIC809 (FAS) - (06/04)
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