<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208773
Report Date: 08/26/2021
Date Signed: 08/26/2021 07:17:31 PM

Document Has Been Signed on 08/26/2021 07:17 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:
6613988802
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY: 99CENSUS: 81DATE:
08/26/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Administrator Ramona ElecoTIME COMPLETED:
07:30 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
An unannounced Health & Safety check was conducted on the date & during the times identified above by Licensing Program Analyst (LPA) K. McClurg. LPA was allowed entry & was joined by Administrator (Admin) Ramona Eleco. LPA stated purpose of visit & was allowed to proceed with visit.

LPA toured facility. Residents in dining room being served dinner. Residents appeared to be appropriately dressed & groomed. Dinner consisted of hamburger patties with buns, chili beans, & cole slaw. Food appeared to be generally appealing & portions sufficient. Sufficient seating, tables, & lighting in dining room. Medication stored in locked room. Passageways observed to be clear & free of obstruction. Facility staff in process of cleaning/general housekeeping. Cleaning cart containing miscellaneous cleansers & Raid bug spray observed in hallway outside of room while staff was in resident room #39 cleaning. Cleansers/bug spray observed to be accessible to residents when cart is outside of room in hallway while staff are in resident rooms cleaning.

Health & Safety check completed. Deficiency issued.

Exit interview conducted with Admin. Report provided.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE: DATE: 08/26/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/26/2021
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 2
Document Has Been Signed on 08/26/2021 07:17 PM - It Cannot Be Edited


Created By: Kelly J. McClurg On 08/26/2021 at 05:27 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: 08/26/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/27/2021
Section Cited
CCR
87309(a)

1
2
3
4
5
6
7
Storage Space - Disinfectants, cleaning solutions, poisons,...shall be... inaccessible to clients. Cleaning cart containing
1
2
3
4
5
6
7
Administrator agrees to submit plan of how cleansers, & other items used by housekeeping that pose a risk will be made inaccessible while in use.
8
9
10
11
12
13
14
miscellaneous cleansers & bug spray observed in hallway outside of room while staff was cleaning in resident room.
8
9
10
11
12
13
14
Plan to include all staff training. Plan to be submitted by due date. Copy of completed training to be submitted after training completed.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Andy Xiong
LICENSING EVALUATOR NAME:Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2