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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206768
Report Date: 01/31/2025
Date Signed: 01/31/2025 02:59:05 PM

Document Has Been Signed on 01/31/2025 02:59 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:JASMINE GARDEN RESIDENTIAL CARE IIFACILITY NUMBER:
157206768
ADMINISTRATOR/
DIRECTOR:		BARCELONA, NELIAFACILITY TYPE:
740
ADDRESS:14012 TOLUCA DRIVETELEPHONE:
(661) 829-6818
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY: 6CENSUS: 4DATE:
01/31/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:56 AM
MET WITH:Administrator: Marc BarcelonaTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 1/31/25 Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced himself, stated the purpose of the visit, and was greet by Staff (S1) Sun Sun Wai, LPA was granted entry. 4 residents were present during inspection. Administrator (A1) Marc Barcelona arrived shortly after LPA’s arrival.

LPA toured facility with A1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. A sample of resident’s medications were checked and observed kept locked in medication cabinet. Lisinopril 20 mg 1 tab by mouth taken twice daily, the label says once daily and MARS and Centrally Stored Medication Record says medication should be taken twice daily. Clients’ MARS was reviewed. D3 1000 1 tab taken by mouth once daily has not been signed off since 1/19/25. Fire extinguisher reviewed with a service date of: 3/26/24. Fire drill last completed on 1/7/25. Clients' bedrooms were toured and reviewed. Cleaning chemicals was observed stored and locked in facility cabinet. Resident's rooms were observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested at a range of 112.6 to 115.7 degrees F in 2 bathrooms.

Outside of facility toured. Outside observed free of debris. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for clients. Freezer temperature was maintained at 0 degrees F and refrigerator temperature was maintained range at 40 degrees F. Carbon monoxide were tested and observed to be operational. All clients’ files reviewed to have all the required documents. All staff files were reviewed to have all required documents.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: JASMINE GARDEN RESIDENTIAL CARE II
FACILITY NUMBER: 157206768
VISIT DATE: 01/31/2025
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1 deficiency is being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. LPA is requesting the following documents be submitted to the Fresno CCL office by 2/14/25: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance-RCFE, Emergency and Disaster Plan (LIC 610E -RCFE), Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A- RCFE)

A copy of this report and appeal rights was provided to A1, whose signature on this form confirms receipt of this report.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/31/2025 02:59 PM - It Cannot Be Edited


Created By: Jacques Leffall On 01/31/2025 at 02:39 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 II
FACILITY NUMBER: 157206768

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 out of 8 medications for 1 resident, D3 1000 1 tab by mouth daily has not been signed off since 1/19/25 on MARS and
Lisinopril 20 mg take 1 tab by mouth twice daily. Label reads take 1 tab by mouth once a day. Label needs to be updated and match MARS and Centrally Stored Medication Record which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/01/2025
Plan of Correction
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Licensee agrees that all staff complete medication training and submit written documentation of completion of training by POC due date.
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:See Moua
LICENSING EVALUATOR NAME:Jacques Leffall
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2025


LIC809 (FAS) - (06/04)
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