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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157208773
Report Date: 08/15/2022
Date Signed: 08/15/2022 12:36:38 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/29/2022 and conducted by Evaluator Kamaldeep Kaur
COMPLAINT CONTROL NUMBER: 24-AS-20220729080056
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: 79DATE:
08/15/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Ramona Eleco TIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff did not give medication(s) to resident according to doctor’s orders.
Resident’s shower door is in disrepair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) K. Kaur and Licensing Program Manager S. Moua conducted a subsequent complaint inspection to deliver findings. LPA and LPM met with Administrator Ramona. Findings were delivered.

The Department has interviewed staff and residents, toured the facility, and reviewed records. Based on observation R1’s shower door was not latching and staying closed. A sample review of the medication was conducted, and files reviewed. R1 and R2 medication reviewed and was found that medication was missed and or not properly handled.

Exit Interview was conducted.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 24-AS-20220729080056
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: JASMIN TERRACE AT BAKERSFIELD
FACILITY NUMBER: 157208773
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/16/2022
Section Cited
CCR
87465(a)(4)
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87465(a)(4)A plan for incidental medical and dental care shall be developed by each facility. .....provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.

This requirement was not met as evidenced by:
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A reconcile is completed for all the medications given on a daily basis. On a weekly basis administrator is reviewing/ reconciling all MARs/medication.
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A sample of the medication was conducted, and files reviewed. R1 and R2 medication's were reviewed and was found that medication was missed and or not properly handled.
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Type B
09/02/2022
Section Cited
CCR
87303(e)(6)
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87303(e)(6) (e)Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition.



This requirement was not met as evidenced by:
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Shower door latch was repaired during visit
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 Based on observation R1’s shower was not latching and staying closed.
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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.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 08/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2