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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607655
Report Date: 10/27/2021
Date Signed: 10/27/2021 03:01:15 PM

Document Has Been Signed on 10/27/2021 03:01 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: 114DATE:
10/27/2021
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:11 AM
MET WITH:Rocio Gonzalez -Wellness Director and
Virgnia Garcia - Administrator 		TIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst(s)(LPAs) Mary Flores and Jewel Baptiste conducted a case management continuation annual visit focus on domains Personnel Records/Staff Training, Operational Requirements, Staffing, and Planned Activities. LPAs met with Lori Lackey assistant administrator and explained the reason for the visit.

During this visit LPAs toured the facility to follow up with Infection Control guidance. LPAs observed English and Spanish signs throughout the facility, closed trash cans in common areas, disinfection time sheets throughout the facility with logging times for every shift. Staff were observed wearing surgical mask, one person per table was observed in dining room, disinfecting spray bottles have been updated. LPA observed a staff washing hands and a staff donning and doffing were done properly.

LPAs reviewed staff files for staff #1(S1), #2(S2), #3(S3), #4(S4), #5(S5), #6(S6), #7(S7), #8(S8), #9(S9), facility's plan of operation, facility's activity calendar for 3 months, and in service training which total approximately 4 hours between 12/24/20 - 5/10/21. LPAs observed S1, S2,S5,S9 do not have a current First Aid/CPR training and S6 did not have a health screening/TB test. LPAs observed Administrator Certificate # 6020807740 expiration date: 10/14/22 for Virginia Garcia Administrator and obtained a copy of insurance bond with expiration date of 1/31/22.

Deficiencies were given under Title 22 Regulations Division 6 Chapter 8 and noted on LIC 809D.

Exit interview was conducted with Virginia Garcia, administrator and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2021
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 3
Document Has Been Signed on 10/27/2021 03:01 PM - It Cannot Be Edited


Created By: Mary G Flores On 10/27/2021 at 01:05 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: 10/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

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 in 9 out of 9 staff files reviewed did not have 20 hours of training in the topics above which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/10/2021
Plan of Correction
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Administrator will ensure that all staff complete 20 hours yearly training in the topics describe in section HSC 1569.625(b)(2) and submit a copy to the department by 11/10/21.
Type B
Section Cited
CCR
87411(c)(1)
87411 Personnel Requirements: (c)All RCFE staff who assist residents with personal activities of daily living shall receive ... (1) Staff providing care shall receive appropiate training in first aid from persons qualified by such agencies as American Red Cross.

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 in 4 out of 9 staff files (S1,S2,S5,S9) reviewed did not have a current CPR training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2021
Plan of Correction
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Administrator will ensure that all staff providing care have a current CPR/First Aid training and submit a copy of the certificate by 11/3/21.
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: 10/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2021


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/27/2021 03:01 PM - It Cannot Be Edited


Created By: Mary G Flores On 10/27/2021 at 01:41 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: 10/27/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
87411(f) Personnel Requirements - (f) All personnel, including the licensee and the administrator shall be in good health, and physically and mentally capable of performing assigned task. Good physical health should be verify by health screening, including a chest X-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure...

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 in 1 out of 9 staff does not have a health screening and TB test on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/03/2021
Plan of Correction
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Adminsitrator will ensure all staff have all require licensing documents and will provide a copy of the S6's health screening and TB test by 11/3/21 to the department.
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: 10/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2021


LIC809 (FAS) - (06/04)
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