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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607655
Report Date: 11/04/2021
Date Signed: 11/04/2021 01:41:39 PM

Document Has Been Signed on 11/04/2021 01:41 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:
11/04/2021
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:51 AM
MET WITH:Lori Lackey Assistant Administrator and
Virgnia Garcia - Administrator 		TIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Mary Flores conducted a case management - annual continuation visit with focus on Disaster Preparedness, Residents with Special Health Needs, and Residents Rights Information domains. LPA Flores met with Lori Lackey assistant administrator and explain the reason of the visit.

LPA conducted a tour with Lori Lackey and observed 3 stairways/emergency exits each staircase has an evacuation chair on the second floor, LPA observed oxygen signs posted outside the door in rooms #205,228,230,233,243,252,258,126,130,131,110 and enter rooms #126, 130,131,110 and observed oxygen tanks in stands. LPA observed a storage closet with a substantial amount of water jugs in the first floor, fire extinguishers are located in each floor throughout the floor plan and tags were observed to be check at least once a month. LPA observed emergency food supplies in kitchen's pantry with an expiration date of 2/20/41. LPA Flores interviewed five staff, and six residents, and reviewed emergency disaster plan binder. This concludes annual visit for the facility.

LPA observed facility is following current COVID 19 guidelines and recommendations per PINs and CDC guidelines.

No deficiencies were found during this visit. Technical assistance were provided.

Exit interview was conducted with Virginia Garcia administrator and a copy of this report was provided.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2021
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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