<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
157202402
Report Date:
11/20/2024
Date Signed:
11/20/2024 01:31:49 PM
Document Has Been Signed on
11/20/2024 01:31 PM
- 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 CARE
FACILITY NUMBER:
157202402
ADMINISTRATOR/
DIRECTOR:
BARCELONA, MARC OR NELIA
FACILITY TYPE:
740
ADDRESS:
14016 TOLUCA DRIVE
TELEPHONE:
(661) 410-8297
CITY:
BAKERSFIELD
STATE:
CA
ZIP CODE:
93314
CAPACITY:
6
CENSUS:
4
DATE:
11/20/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME VISIT/
INSPECTION BEGAN:
10:48 AM
MET WITH:
Assistant Administrator, Myat Tusaw
TIME VISIT/
INSPECTION COMPLETED:
01:46 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/20/2024, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and was granted entry to the facility. Administrator, Marc Barcelona, is not able to attend this inspection. LPA met with assistant Administrator, Myat Tusaw.
LPA reviewed facility records and found the following: Upon review of resident records, LPA found that 3 out of 4 residents did not have a needs and services/care plan on file. Facility did not have records available to review for 2 out of 2 staff on duty. LPA did not observe initial/annual training in the employee training file for 2 out of 2 staff on duty. Emergency disaster plan was not updated. Last documented fire drill was conducted on 01/22/2024. Medications reviewed. LPA found multiple medications not stored in their original container and stored in zip-lock bags. LPA observed multiple over-the-counter medications being administered to residents in care, facility did not have a prescription or documentation showing the medication was authorized by a physician. Fire extinguisher was last serviced on 03/26/2024.
LPA conducted a facility tour with Assistant Administrator. Common areas were observed to be furnishing and had adequate lighting. LPA toured resident bedrooms. Bedrooms observed to have required furnishings. LPA toured facility bathrooms. Hot water measured at 99.3 degrees F. LPA observed a bottle of Clorox disinfectant wipes accessible to residents in care under the bathroom sink. Kitchen toured. LPA observed an adequate food supply. LPA observed the cabinet under the kitchen sink to be unlocked. The cabinet stores cleaning supplies including Ajax that were accessible to residents in care. LPA observed the medication cabinet to be unlocked and accessible to persons other than facility staff. LPA observed an adequate supply of linens.
Exterior tour conducted. Exits were open and free from obstructions during today's inspection. CONTINUED TO 809C
SUPERVISORS NAME
:
Melinda Hoffmann
LICENSING EVALUATOR NAME
:
Alexandria Walton
LICENSING EVALUATOR SIGNATURE
:
DATE:
11/20/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/20/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1314 E SHAW AVE
FRESNO
,
CA
93710
FACILITY NAME:
JASMINE GARDEN RESIDENTIAL CARE
FACILITY NUMBER:
157202402
VISIT DATE:
11/20/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Deficiencies are being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D.
During the annual inspection on 12/18/2023, the facility received deficiencies for California Code of Regulations sections 87303 and 87309. Civil penalties in the amount of $500 is being assessed for repeat violations of sections 87303(e)(2) and 87309(a).
Exit interview conducted and a plan of correction was reviewed and developed. A copy of this report and appeal rights were discussed and provided to Assistant Administrator, Myat Tusaw, whose signature on this form confirms receipt of these documents.
LPA discussed the Technical Support Program (TSP) with the facility representative. L
PA offered to refer the facility to TSP. Facility representative accepted the offer on behalf of the Administrator.
LPA is requesting the following documents be submitted to the Fresno CCL office by 12/04/2024: 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*
SUPERVISORS NAME
:
Melinda Hoffmann
LICENSING EVALUATOR NAME
:
Alexandria Walton
LICENSING EVALUATOR SIGNATURE
:
DATE:
11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/20/2024
LIC809
(FAS) - (06/04)
Page:
9
of
9
Document Has Been Signed on
11/20/2024 01:31 PM
- It Cannot Be Edited
Created By:
Alexandria Walton
On
11/20/2024
at
12:49 PM
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:
11/20/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above when disinfectants were observed to be accesible to residents in the kitchen and bathroom in which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
11/21/2024
Plan of Correction
1
2
3
4
Licensee agrees to submit a written statement detailing the facility's plan to ensure the requirements for this section is met to the Fresno CCL office. The plan should include details of how the facility will train staff on this requirement.
Type A
Section Cited
CCR
87465(a)(5)(A)
Incidental Medical and Dental Care Services
(5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following: (A) Medications usually prescribed for self-administration which have been authorized by the person's physician.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above when the facility administered over-the-counter medication without authorization from a primary physician, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
11/21/2024
Plan of Correction
1
2
3
4
Licensee agrees to submit a written statement detailing the facility's plan to ensure the requirements for this section is met to the Fresno CCL office. The plan should include details of how the facility will not store and administer medications that are not authorized by a primary physician.
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:
11/20/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/20/2024
LIC809
(FAS) - (06/04)
Page:
2
of
9
Document Has Been Signed on
11/20/2024 01:31 PM
- It Cannot Be Edited
Created By:
Alexandria Walton
On
11/20/2024
at
12:49 PM
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:
11/20/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above when medications were observed to be accessible to persons other than employees, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
11/21/2024
Plan of Correction
1
2
3
4
Licensee agrees to submit a written statement detailing the facility's plan to ensure the requirements for this section is met to the Fresno CCL office by the POC due date.. The plan should include details of how the facility will train staff on this requirement
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above when medications were not stored in the original container, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
11/21/2024
Plan of Correction
1
2
3
4
Licensee agrees to submit a written statement detailing the facility's plan to ensure the requirements for this section is met to the Fresno CCL office by the POC due date.. The plan should include details of how the facility will train staff on this requirement.
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:
11/20/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/20/2024
LIC809
(FAS) - (06/04)
Page:
3
of
9
Document Has Been Signed on
11/20/2024 01:31 PM
- It Cannot Be Edited
Created By:
Alexandria Walton
On
11/20/2024
at
12:49 PM
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:
11/20/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above when hot water measured at 99.3 degrees F. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/28/2024
Plan of Correction
1
2
3
4
Licensee agrees to adjust the water heater and document the water temperature for approximately 1 week and submit a copy of the water log to the Fresno CCL office by the POC due date.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review)], the licensee did not comply with the section cited above in 2 out of 2 persons on duty which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/28/2024
Plan of Correction
1
2
3
4
Licensee agrees to submit a written statement detailing the facility's plan to ensure the requirements for this section is met to the Fresno CCL office by the POC due date.. The plan should include details of how the facility maintain updated training and records for all employees.
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:
11/20/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/20/2024
LIC809
(FAS) - (06/04)
Page:
4
of
9
Document Has Been Signed on
11/20/2024 01:31 PM
- It Cannot Be Edited
Created By:
Alexandria Walton
On
11/20/2024
at
12:49 PM
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:
11/20/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 2 out of 2 persons on duty which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/28/2024
Plan of Correction
1
2
3
4
Licensee agrees to submit a written statement detailing the facility's plan to ensure the requirements for this section is met to the Fresno CCL office by the POC due date. The plan should include details of how the facility will maintain updated training records for all employees
Type B
Section Cited
CCR
87465(a)(1)
Incidental Medical and Dental Care Services
(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in 3 out of 4 residents in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/28/2024
Plan of Correction
1
2
3
4
Licensee agrees to submit a written statement detailing the facility's plan to ensure the requirements for this section is met to the Fresno CCL office by the POC due date. The plan should include details of how the facility will develop a care plan for 3 out of 4 residents in care
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:
11/20/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/20/2024
LIC809
(FAS) - (06/04)
Page:
5
of
9
Document Has Been Signed on
11/20/2024 01:31 PM
- It Cannot Be Edited
Created By:
Alexandria Walton
On
11/20/2024
at
12:49 PM
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:
11/20/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above when the facility last conducted a fire drill in January 2024 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/28/2024
Plan of Correction
1
2
3
4
Licensee agrees to submit a written statement detailing the facility's plan to ensure the requirements for this section is met to the Fresno CCL office by the POC due date. The plan should include details of how the facility will conduct fire drills as required by section 1569.695(c).
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
11/20/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/20/2024
LIC809
(FAS) - (06/04)
Page:
6
of
9