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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208773
Report Date: 08/22/2023
Date Signed: 08/22/2023 12:52:05 PM

Document Has Been Signed on 08/22/2023 12:52 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: 75DATE:
08/22/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Ramona ElecoTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analysts (LPA) Shawna Doucette and Licensing Program Manager (LPM) See Moua arrived at the facility unannounced to conduct the continuation of the Required Annual Inspection. LPA and LPM met with Administrator Ramona Eleco. LPA's disclosed the purpose of the inspection and was granted entry into the facility by the Administrator.

LPA and LPM toured the facility and reviewed records. Photos were taken.

Deficiencies were issued on 809D.

An exit interview was conducted and a copy of this report, plan of corrections and appeal rights were provided to Administrator Ramona Eleco

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023
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 8
Document Has Been Signed on 08/22/2023 12:52 PM - It Cannot Be Edited


Created By: Shawna Doucette On 08/22/2023 at 11:40 AM
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: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
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
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Based on observation, the licensee did not comply with the section cited above in by residents rooms measuring above 125 F and under 85F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2023
Plan of Correction
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Plan of Correction POC Licensee agrees to meet this regulation of water measuring between 105F to 120F. Licensee agrees to submit documentation of proof by POC due date.
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by medicaitons were not administered/logged as being administered for several residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2023
Plan of Correction
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Plan of Correction POC Licensee agrees to submit copy of training for medication technicians by POC due date.
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:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023


LIC809 (FAS) - (06/04)
Page: 2 of 8
Document Has Been Signed on 08/22/2023 12:52 PM - It Cannot Be Edited


Created By: Shawna Doucette On 08/22/2023 at 11:40 AM
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: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)
Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review and intervies, the licensee did not comply with the section cited above by not having a plan of operation at the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2023
Plan of Correction
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Plan of Correction POC Licensee agrees to submit a photo of the facility's plan of operation to licensing by the POC due date.
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by shared bathroom needing to be cleaned with toilet seat in bathroom shower and wash cloth on ground, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
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Plan of Correction POC Licensee agrees to clean shared bathroom and submit a photo by POC due date.
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:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023


LIC809 (FAS) - (06/04)
Page: 3 of 8
Document Has Been Signed on 08/22/2023 12:52 PM - It Cannot Be Edited


Created By: Shawna Doucette On 08/22/2023 at 11:40 AM
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: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by licensee not having admission agreements signed for residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
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Plan of Correction POC Licensee agrees to provide a written understanding of this regulation and how it will be met by POC due date.
Type B
Section Cited
CCR
87456(a)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and observation, the licensee did not comply with the section cited above by having residents in care that require a higher level of care, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/25/2023
Plan of Correction
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Plan of Correction POC Licensee agrees to submit a written understanding of this regulation and how it will be met by POC due date.
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:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023


LIC809 (FAS) - (06/04)
Page: 4 of 8
Document Has Been Signed on 08/22/2023 12:52 PM - It Cannot Be Edited


Created By: Shawna Doucette On 08/22/2023 at 12:15 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: 08/22/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(d)


Personnel Requirement 87411(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:

This requirement is not met as evidenced by:

Based on records review and interviews, the licensee did not comply with the section cited above by staff not having any current training, which poses/posed a potential health, safety or personal rights risk to persons in care.

.
Deficient Practice Statement
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Based on records review and interviews, the licensee did not comply with the section cited above by staff not having any current training, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/22/2023
Plan of Correction
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Plan of Correction POC Licensee agrees to complete a plan for training for all staff to meet all training regulations by POC due date 09/22/23. Licensee agrees to have all training completed for staff by 11/1/23.
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:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Shawna Doucette
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023


LIC809 (FAS) - (06/04)
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