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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607655
Report Date: 12/08/2021
Date Signed: 12/08/2021 03:44:53 PM

Document Has Been Signed on 12/08/2021 03:44 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: DATE:
12/08/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Virginia Garcia - AdministratorTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced case management visit regarding incident report fax to the department on 12/7/21.LPA met with Virginia Garcia administrator.

On 12/7/21 LPA Flores reviewed incident report stating Resident #1 (R1) was noted missing around 6:00pm. Facility found out R1 left the facility by patio door at 1:30pm. Patio door was open as plumbing contractors were using door to come into the facility and conduct repairs. Facility contacted responsible party and Police Department on 12/2/21. On 12/7/21 LPA Flores requested physician's report, admission agreement, pre-appraisal agreement, needs and care plan, and medication sheet. LPA reviewed R1 physician's report which notes resident is able to leave the facility unattended. During today's visit LPA requested a copy of the police reference number/contact, employee warning notice form for staff #1, and #2, and observed the patio door. Patio door is located to the left of the main entrance, there is a blocked patio with no access to the door and it has a working egress system. Per administrator access was provided to contractors by removing planters and overriding egress system to allow contractors access with equipment on 12/2/21.

Per mitigation plan and current COVID guidelines one entry point must be designated for screening, sign in and out.

Deficiencies have been noted on LIC 809D under Title 22 Regulations.

Exit interview was conducted and a copy of this report, LIC 809D, and appeal rights have been provided.
SUPERVISORS NAME: Rebecca Orendain
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2021
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 12/08/2021 03:44 PM - It Cannot Be Edited


Created By: Mary G Flores On 12/08/2021 at 02:04 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: 12/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/09/2021
Section Cited
CCR
87468.1

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87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement is not met as evidence by:
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Administrator will ensure to maintain one entry point to the facility at all times. In-service training to be provided to staff and submitted to the department on 12/9/21. LPA observed door is closed and inaccessible.
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Based on documents review and interview conducted Licensee did not ensure to maintain one entrance point at the facility which poses an immediate health, safety, or personal rights risk for persons in care.
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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: 12/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2021


LIC809 (FAS) - (06/04)
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