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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607655
Report Date: 10/19/2021
Date Signed: 10/19/2021 03:50:16 PM

Document Has Been Signed on 10/19/2021 03:50 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:JASMIN TERRACE AT EL MOLINOFACILITY NUMBER:
197607655
ADMINISTRATOR:VIRGINIA GARCIAFACILITY TYPE:
740
ADDRESS:245 S. EL MOLINO AVE.TELEPHONE:
(626) 578-0460
CITY:PASADENASTATE: CAZIP CODE:
91101
CAPACITY: 206CENSUS: 121DATE:
10/19/2021
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:47 AM
MET WITH:Rocio Gonzalez -Wellness Director and
Virgnia Garcia - Administrator 		TIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst(s) Mary Flores and Jewel Baptiste conducted a case management - annual continuation visit with focus on Incidental Medical and Dental, Residents Records/Incident Reports. LPAs met with Virginia Garcia - Administrator and explained the reason for the visit.

During today's visit LPAs reviewed medication and resident files for residents #1(R1), #2(R2) , #3(R3), #4(R4), #5(R5), #6(R6), #(7(R7), #8(R8), #9(R9), #10(R10), #11(R11), #12(R12). LPAs observed non prescription medication (PRN) for R3,R4,R8,R11 did not have label.

Per Title 22 Regulations deficiencies were cited today under section 8 chapter 6 and noted on LIC 809D.

Exit interview conducted with Virginia Garcia administrator and a copy of the report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2021
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 10/19/2021 03:50 PM - It Cannot Be Edited


Created By: Mary G Flores On 10/19/2021 at 03:31 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
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: JASMIN TERRACE AT EL MOLINO
FACILITY NUMBER: 197607655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(e)
For every prescription and non prescription 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 residents 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, the licensee did not comply with the section cited above in 4 out of 12 resident's PRN medication reviewed did not have a label on them which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/26/2021
Plan of Correction
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Licensee will ensure that all PRN medication is label at all times. Licensing will submit pictures of the medication by 10/26/21.
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:Rebecca Orendain
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2021


LIC809 (FAS) - (06/04)
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