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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208773
Report Date: 06/18/2024
Date Signed: 06/18/2024 09:26:53 PM

Document Has Been Signed on 06/18/2024 09:26 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/
DIRECTOR:		ELECO, RAMONA D.FACILITY TYPE:
740
ADDRESS:5400 STINE ROADTELEPHONE:
(661) 398-8802
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY: 99CENSUS: 76DATE:
06/18/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:34 AM
MET WITH:Administrator Ramona ElecoTIME VISIT/
INSPECTION COMPLETED:
09:45 PM
NARRATIVE
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Licensing Program Analysts (LPA)'s Shawna Doucette and Brianna Miranda arrived at the facility unannounced to conduct the Required Annual Inspection. LPAs were granted entry by Staff Darlene Ruano. Staff contacted the Administrator who responded to the facility to assist with the visit. LPAs met with Administrator Ramona Eleco.

LPAs toured the facility. LPAs smelled a strong odor of urine and the bathroom counter to be dirty in Room 30. LPAs observed a bed with only the bottom sheet with a brown substance on the bottom sheet of Room 49. LPAs observed the community shower to be dirty with a trash can and a broom inside the shower. LPAs observed Room 50 to have an unknown liquid substance on the floor. LPAs observed cleaning supplies on the bed in Room 51. LPAs observed the foot and head of the bed in Room 53 to be slanting. LPA's observed a dirty diaper on the floor in Room 17. LPAs observed urine on the floor and the hoyer lift in Room 33. Room 67 had a dirty floor. LPAs took photos. LPAs observed R1 in the geri chair for majority of the day. LPA Doucette spoke to R1's family who advised R1 awoled awhile back. LPA's could not locate an awol report submitted to licensing. LPA Miranda did a case management for reporting requirements and incidental and medical. At 6:45 PM LPA's observed R1 in his geri chair unsupervised in the medication room while the medication technician opened the front door in reaching distance of medications.

LPAs toured of the outside of the facility where LPAs observed torn screens and the fascia board to be rotting. The dining exit door to the courtyard is broken. LPAs took photos. Facility has outdoor seating for residents.

LPAs reviewed resident's medication and files. LPAs interviewed staff and residents and found staff are administering injections to residents. R7's physicians report states R7 is unable to administer own injections or check glucose. LPA obtained a copy of R7's LIC602. This was addressed with Administrator on 8/22/23 per inspection notes. LPAs found medication errors for R7 and R8. Facility staff are crushing medications

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
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 34
Document Has Been Signed on 06/18/2024 09:26 PM - It Cannot Be Edited


Created By: Shawna Doucette On 06/18/2024 at 01:13 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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items 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:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in Licensee had cleaning supplies left unattended on R2's neighboring bed in room 51, which poses an immediate health, safety or personal rights risk to persons in care. Photos were taken.
POC Due Date: 06/19/2024
Plan of Correction
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2
3
4
Licensee agrees to conduct a staff training on locking up cleaning supplies by POC due date. Licensee agrees to submit copy of staff training with agenda and certificates.
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
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in Licensee did not administer R7's medication by having one missed day, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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2
3
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Licensee agrees to conduct a medication training. Licensee agrees to submit date of training and agenda for training by POC due date 6/19/24. Photos were taken. Civil Penalty issued.
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: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
Page: 2 of 34
Document Has Been Signed on 06/18/2024 09:26 PM - It Cannot Be Edited


Created By: Shawna Doucette On 06/18/2024 at 01:13 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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(5)
Incidental Medical and Dental Care Services
(5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in Licensee is allowing S3 to administrer R7's injections, which poses an immediate health, safety or personal rights risk to persons in care. R7's LIC 602 states R7 cannot administer own medications and S3 is not a licensed professional.
POC Due Date: 06/19/2024
Plan of Correction
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Licensee agrees to come up with a plan to move R7 to a higher level of care. Licensee will contact R7's conservator and submit plan by POC due date 06/19/24.
Type A
Section Cited
CCR
87465(a)(5)(D)
Incidental Medical and Dental Care Services
(5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed. Assistance with self-administered medications shall be limited to the following: (D) Assistance with self-administration does not include forcing a resident to take medications, hiding or camouflaging medications in other substances without the resident's knowledge and consent, or otherwise infringing upon a resident's right to refuse to take a medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above in Licensee is crushing and administering R9's medications camoflauging them in R9's coffee, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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Licensee agrees to contact the doctor to get an order for crushing the medication and putting it in drink/food by POC due date 06/19/24. Licensee will submit a copy of the order and submit a written understanding of the regulation by POC due date 6/19/24.
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: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
Page: 3 of 34
Document Has Been Signed on 06/18/2024 09:26 PM - It Cannot Be Edited


Created By: Shawna Doucette On 06/18/2024 at 01:13 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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in Licensee did not meet this regulation by administering CVS stomach relief, Kirkland acetaminophen and amazon allergy relief without a prescription to miscellaneous residents that request the medication, which poses an immediate health, safety or personal rights risk to persons in care. Photos of the non prescription medications were taken.
POC Due Date: 06/19/2024
Plan of Correction
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Licensee agrees to submit a written statement showing the understanding of the regulation by POC due date 6/19/24.
Type A
Section Cited
CCR
87465(b)
Incidental Medical and Dental Care Services
(b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in Licensee did not have a physician stating R8 and R11 could communicate the need for a prescription or non prescription medication, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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Licensee agrees to obtain a doctors note in writing stating whether or not residents are able to determine the need for a prescription or nonprescriotion medication by POC due date. Licensee agrees to submit the doctor note for R8 and R11.
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: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
Page: 4 of 34
Document Has Been Signed on 06/18/2024 09:26 PM - It Cannot Be Edited


Created By: Shawna Doucette On 06/18/2024 at 01:13 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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

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 Licensee did not have a written physician order on a prescription blank for R8 and R11 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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Licensee agrees to obtain prescription blank with physician's orders for R8 and R11 by POC due date 6/19/24.
Type A
Section Cited
HSC
1569.695(a)
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation interview record review, the licensee did not comply with the section cited above in Licensee did not have a disaster plan or a plan for dementia residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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3
4
Licensee agrees to submit a disaster plan to licensing on POC due date 06/19/24
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: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
Page: 5 of 34
Document Has Been Signed on 06/18/2024 09:26 PM - It Cannot Be Edited


Created By: Shawna Doucette On 06/18/2024 at 01:13 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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(1)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (1) Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation interview record review the licensee did not comply with the section cited above in R1 is in a geri chair all day without a doctors note to advise purpose or use of geri chair, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
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2
3
4
Licensee agrees to get a physicians note identifying the use of the geri chair and identify when it is supposed to be used by POC due date 06/19/24. Licensee agrees to submit a copy of the the physicians note.
Type A
Section Cited
CCR
87628(a)
Diabetes
(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview record review, the licensee did not comply with the section cited above in Licensee accepted R7 who's LIC 602 states R7 cannot administer R7's own injections or glucose testing, which poses an immediate health, safety or personal rights risk to persons in care. LPA's were unable to determine if R10 can administer own injections due to R10 not having a LIC602a.
POC Due Date: 06/19/2024
Plan of Correction
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2
3
4
Licensee agrees to make doctor appointments and submit apppointment dates for all diabetic residents recieving injecitons to obtain the correct form LIC602a by POC due date 06/19/24.
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: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
Page: 6 of 34
Document Has Been Signed on 06/18/2024 09:26 PM - It Cannot Be Edited


Created By: Shawna Doucette On 06/18/2024 at 01:13 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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(c)(4)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in R1 is locked in a geri chair in the dining area with no log of how often R1 is allowed out of the chair, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
1
2
3
4
Licensee agrees to submit a plan on how to care for R1 while he is not in the geri chair by POC due date 06/19/24.
Type A
Section Cited
CCR
87705(j)
Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) , the licensee did not comply with the section cited above in Licensee does not have alarms on the front door or the back doors that exit into the courtyard which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 06/19/2024
Plan of Correction
1
2
3
4
Licensee agrees to have alarms on all exit doors and will submit service date of alarms to be put on doors by POC due date 6/19/24.
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: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
Page: 7 of 34
Document Has Been Signed on 06/18/2024 09:26 PM - It Cannot Be Edited


Created By: Shawna Doucette On 06/18/2024 at 01:13 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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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
1
2
3
4
Based on [(observation), the licensee did not comply with the section cited above in Licensee did not clean community shower, Room 17 had a dirty depends on the floor, Room 33 had urine dried on the floor, Room 67 had an unknown dried substance on the floor, Room 50 had an unknown wet substance on the floor, inside the cabinet in the tv room had mold and dead insects, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
1
2
3
4
Licensee agrees to clean the facility by POC due date 07/12/24. Civil Penalty issued.
Type B
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
1
2
3
4
Based on [(observation) (interview), the licensee did not comply with the section cited above in Licensee did not have hot water turned on in R1's room and room 19 was 103.9 and room 6 104.9, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
1
2
3
4
Licensee agrees to submit photos of running hot water in Room 67. Maintenance came before the end of the day and turned the water back on. POC cleared during visit. Civil penalty issued.
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: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
Page: 8 of 34
Document Has Been Signed on 06/18/2024 09:26 PM - It Cannot Be Edited


Created By: Shawna Doucette On 06/18/2024 at 01:13 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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(6)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation), the licensee did not comply with the section cited above in Licensee did not have a working shower head in the TV bathroom, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
1
2
3
4
Licensee agrees to fix or replace shower head by POC due date 06/21/24 and submit photo.
Type B
Section Cited
CCR
87307(a)(3)(C)
Personal Accommodations and Services
(C) Clean linen, including blankets, bedspreads, top bed sheets, bottom bed sheets, pillow cases, mattress pads, bath towels, hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times. The linen shall be in good repair. The use of common wash cloths and towels shall be prohibited.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation), the licensee did not comply with the section cited above in Licensee did not keep Room 49 bottom linen sheet clean, where a brown substance was observed and photographed (only bottom sheet was on the bed) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
1
2
3
4
Licensee agrees to conduct a staff training on changing all bedding and not just the top portion of the bedding by POC due date 06/21/24.
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: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
Page: 9 of 34
Document Has Been Signed on 06/18/2024 09:26 PM - It Cannot Be Edited


Created By: Shawna Doucette On 06/18/2024 at 01:13 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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(2)
Personal Accommodations and Services
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation), the licensee did not comply with the section cited above in Licensee did not maintain fence which is falling down and did not maintain fascia board around the facility is rotting (Photos taken), which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
1
2
3
4
Licensee agrees to repair the fence and fix the facia board on the outside of the facility by POC due date 07/12/24
Section Cited
Other Provisions
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


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Created By: Shawna Doucette On 06/18/2024 at 01:13 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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(7)
General Food Service Requirements
(b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above Licensee does not have a modified diet plan for R6, R7, R10 or R13, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
1
2
3
4
Licensee agrees to provide a plan on how this regulation will be met for pureed diets and diabetic diets by POC due date 06/28/24.
Type B
Section Cited
CCR
87555(b)(17)
General Food Service Requirements
(b) The following food service requirements shall apply: (17) In facilities licensed for fifty (50) or more, and providing three (3) meals per day, a full-time employee qualified by formal training or experience shall be responsible for the operation of the food service. If this person is not a nutritionist, a dietitian, or a home economist, provision shall be made for regular consultation from a person so qualified. The consultation services shall be provided at appropriate times, during at least one meal. A written record of the frequency, nature and duration of the consultant's visits shall be secured from the consultant and kept on file in the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on (interview) (record review)], the licensee did not comply with the section cited above in Licensee did not hire a full time qualified employee with formal training and does not have documentation of a nutritionist, dietician or a home economist visit consultations, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
1
2
3
4
Licensee agrees to submit proof of meeting with qualified professional to meet this regulation by POC due date 07/12/24.
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: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


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Created By: Shawna Doucette On 06/18/2024 at 01:13 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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(8)
Incidental Medical and Dental Care Services
(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview)], the licensee did not comply with the section cited above in Licensee did not have a first aid kit, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
1
2
3
4
Licensee agrees to submit photos and receipt of first aid kit by POC due date 06/21/24
Type B
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee did not document R1's PRN doses, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
1
2
3
4
Licensee agrees to provide training on documenting PRN's date time residents response and the dose of medication. Licensee agrees to submit training certificates that show training agenda, source of training and hours of trained by POC due date 07/12/24.
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: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


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Created By: Shawna Doucette On 06/18/2024 at 01:13 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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (record review)], the licensee did not comply with the section cited above in Licensee did not have a diagnosis for R15 on R15's LIC602 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
1
2
3
4
Licensee agrees to update R15's LIC602 to list a diagnosis by POC due date 07/12/24 and submit to LPA.
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (record review)], the licensee did not comply with the section cited above in Licensees LIC602 diagnosis for R6 did not match hospice diagnosis for R6 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
1
2
3
4
Licensee agrees to update the LIC 602 to reflect R6's current diagnosis by POC due date 07/12/24.
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: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


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Created By: Shawna Doucette On 06/18/2024 at 01:13 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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87606(b)
Care of Bedridden Residents
(b) A facility shall notify the local fire jurisdiction within 48 hours of accepting or retaining any bedridden person, as specified in Health and Safety Code Section 1569.72(f).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on (interview) (record review)], the licensee did not comply with the section cited above in Licensee did not notify fire of bedridden residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/21/2024
Plan of Correction
1
2
3
4
Licensee agrees to provide proof of notifying fire of bedridden by POC due date 06/21/24.
Type B
Section Cited
CCR
87606(f)(3)
Care of Bedridden Residents
(f) To accept or retain a bedridden person, a facility shall ensure the following: (3) Staff records include documentation of staff training specific to Care of Bedridden Residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section in Licensee did not have training for PM Staff on 0n 06/11/24 on how to care for bedridden residents, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
1
2
3
4
Licensee agrees to conduct a staff training for all staff to be in compliance by POC due date 07/12/24.
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: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


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Document Has Been Signed on 06/18/2024 09:26 PM - It Cannot Be Edited


Created By: Shawna Doucette On 06/18/2024 at 01:13 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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87609(b)(4)
Allowable Health Conditions and the Use of Home Health Agencies
(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: (4) The licensee and home health agency agree in writing on the responsibilities of the home health agency, and those of the licensee in caring for the resident's medical condition(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee did not have an agreement in writing with home health regarding the responsibilities of R3's medical condtion, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
1
2
3
4
Licensee agrees to have a written agreement (plan of care) for R3 identifying the responsibilities of the facility and the responsibilities of the home health agency by POC due date 06/28/24.
Section Cited
Allowable Health Conditions and the Use of Home Health Agencies
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/18/2024 09:26 PM - It Cannot Be Edited


Created By: Shawna Doucette On 06/18/2024 at 01:13 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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(a)(2)
Hospice Care for Terminally Ill Residents
(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (2) The licensee remains in substantial compliance with the requirements of this section, with the provisions of the Residential Care Facilities for the Elderly Act (Health and Safety Code Section 1569 et seq.), all other requirements of Chapter 8 of Title 22 of the California Code of Regulations governing Residential Care Facilities for the Elderly, and with all terms and conditions of the waiver.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee is not in substantial compliance by recieving repeated citations and not having proper documentation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2024
Plan of Correction
1
2
3
4
Licensee agrees to provide in writing a statement on how this regulation will be met and how the facility will become compliant by POC due date 07/12/24.

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: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/18/2024 09:26 PM - It Cannot Be Edited


Created By: Shawna Doucette On 06/18/2024 at 01:13 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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(a)(4)
Hospice Care for Terminally Ill Residents
(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident by that resident's hospice agency and agreed to by the licensee and the resident, or prospective resident, or the resident's or prospective resident's Health Care Surrogate Decision Maker, if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee does not have care plans or current/complete plan of care for residents on hospice and R3's plan of care does not match R3's needs, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
1
2
3
4
LIcensee agrees to obtain a written hospice care plan for all residents on hospice and will submit plans of care by POC due date 06/28/24.

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: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/18/2024 09:26 PM - It Cannot Be Edited


Created By: Shawna Doucette On 06/18/2024 at 01:13 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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(b)(6)
Hospice Care for Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: (6) Identification of the training needed, which staff members need this training, and who will provide the training relating to the licensee's responsibilities for implementation of the hospice care plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee did not have staff training on how to use R5's hoyer lift, R1's oxygen equipment which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
1
2
3
4
Licensee agrees to have hospice train all staff on the use of equipment provided to all residents on hospice. Staff training provided to each individual hospice care plan that requires equipment by POC due date 06/28/24.
Type B
Section Cited
CCR
87633(d)
Hospice Care for Terminally Ill Residents
(d) The licensee shall ensure that the hospice care plan is current, accurately matches the services actually being provided, and that the client's care needs are being met at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee did not have current care plan for R6 which stated R6 was ambulatory but needed to be turned every two hours and the care plan was expired, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
1
2
3
4
Licensee agrees to have current care plans that are accurate to each resident. Licensee agrees to submit an updated, current care plan by POC due date 06/28/24.
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: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/18/2024 09:26 PM - It Cannot Be Edited


Created By: Shawna Doucette On 06/18/2024 at 01:13 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: 06/18/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(3)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in Licensee does not have correct dementia training for all staff] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/19/2024
Plan of Correction
1
2
3
4
Licensee agrees to provide dementia training to meet all dementia training requirements by POC due date 07/19/24.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024


LIC809 (FAS) - (06/04)
Page: 19 of 34
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
VISIT DATE: 06/18/2024
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
26
27
28
29
30
31
32
without a physician order and putting it in R9's coffee. R8's PRN was not administered or logged properly showing out 90 pills records indicated only 26 were administered however there were only 8 pills left. LPA took photos.

Facility does not have hospice or home health care plans or do not have current or accurate care plans for residents on hospice or home health. Facility does not have RCFE (602A) for majority of residents to indicate whether or not a resident has dementia.

Administrator was not able to provide verification of Hoyer Lift training, training for caring for bedridden residents, or current training for staff.

Fire extinguisher was serviced 5/30/24.

Refer to 809D. Civil penalties were issued for repeat violations. Refer to Case Management for additional citations during visit.

A copy of this report was provided to the Administrator.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Shawna Doucette
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC809 (FAS) - (06/04)
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