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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208773
Report Date: 08/04/2021
Date Signed: 08/04/2021 04:04:08 PM

Document Has Been Signed on 08/04/2021 04:04 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:JASMIN TERRACE AT BAKERSFIELDFACILITY NUMBER:
157208773
ADMINISTRATOR:ELECO, RAMONA D.FACILITY TYPE:
740
ADDRESS:5400 STINE ROADTELEPHONE:
(661) 398-8802
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY: 99CENSUS: 81DATE:
08/04/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Ramona Eleco, Administrator TIME COMPLETED:
04:15 PM
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Licensing Program Analysts (LPAs) Shawna Doucette and Lady Cabrera while investigating complaint and toured the inside and outside of the facility.

LPAs interviewed Resident (R1) in her bedroom. LPAs observed a Lysol on top of her bathroom counter. Chemicals were unsecured and accessible to the resident.

During the investigation, it was discovered that facility is not keeping a centrally log medications for residents in care.

Deficiencies cited on the attached 809D. Exit interview conducted.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE: DATE: 08/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/04/2021
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 08/04/2021 04:04 PM - It Cannot Be Edited


Created By: Lady Cabrera On 08/04/2021 at 02:49 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: JASMIN TERRACE AT BAKERSFIELD
FACILITY NUMBER: 157208773

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/04/2021
Section Cited
CCR
87309(a)

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87309 Storage Space(a)Disinfectants, cleaning solutions...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:
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Licensee to lock and secure all chemicals and ensure they are inaccessible to residents in care.

*CLEARED AT TIME OF VISIT
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Based on observation, the licensee did not stored cleaning solutions, which poses an Immediate health, safety or personal rights risk to persons in care.
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Type B
08/19/2021
Section Cited
CCR87506(b)(14)

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87506 Resident Records (b) Each resident’s record shall contain at least the following information: (14) Current centrally stored medications as specified in Section 87465, Incidental Medical and Dental Care Services. This requirement was not met as evidenced by:

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Plan of Correction POC Licensee agrees to provide copies of centrally stored log for the month of July and August for all residents in care.
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Facility not keeping a centrally stored medication log for residents in care. Based on interviews and records review facility was not keeping a centrally stored log for medications of residents in care, which poses a potential health, safety or personal rights risk to persons 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.
SUPERVISOR'S NAME:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Lady Cabrera
LICENSING EVALUATOR SIGNATURE:
DATE: 08/04/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/04/2021


LIC809 (FAS) - (06/04)
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