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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607655
Report Date: 03/11/2025
Date Signed: 03/11/2025 04:44:58 PM

Document Has Been Signed on 03/11/2025 04:44 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:JASMIN TERRACE AT EL MOLINOFACILITY NUMBER:
197607655
ADMINISTRATOR/
DIRECTOR:		VIRGINIA GARCIAFACILITY TYPE:
740
ADDRESS:245 S. EL MOLINO AVE.TELEPHONE:
(626) 578-0460
CITY:PASADENASTATE: CAZIP CODE:
91101
CAPACITY: 206CENSUS: 144DATE:
03/11/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:46 PM
MET WITH:Rocio Gonzalez - Wellness DirectorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced continuous annual visit using the CARE inspection tool. LPA met with Virginia Garcia Administrator and explained the reason for the visit.

On 2/24/25 LPA Flores conducted an annual visit and completed the following domains: Physical Plant/Environmental Safety: see report dated 2/24/25 for details.
Food Service: sufficient food supplies were observed for at least 2 days of perishables and 7 days of non-perishables. Special diets are posted in the kitchen.
Incidental Medical and Dental: medication was reviewed for 10 residents.

During today visit LPA Flores complete the following domains: reviewed 10 resident and 10 staff files.
Infection Control: Facility meets infection control procedures and the plan was reviewed. Staff have a TB test on file.
Operational Requirements: LPA reviewed liability insurance which is current and meets all requirements.
Staffing: Per LIC 500 there is sufficient staffing, there are 5 staff during the night shift and a front desk person. Staff have CPR/First Aid on file.
Personnel Records/Staff Training: Ten staff files were reviewed with the required documentation. Initial and yearly 20 hours of training were observed for each staff. Administrator certificate was observed for Virginia Garcia #7006263740 exp. date: 10/14/26.
Resident Rights/Information: Resident rights, PUB 475, Ombudsman poster were posted in common areas of the facility.
Planned Activities: Activities calendar is posted in the activity area. An activity director is on duty and activities for persons with dementia were observed.

(CONTINUED ON LIC 809C)
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: JASMIN TERRACE AT EL MOLINO
FACILITY NUMBER: 197607655
VISIT DATE: 03/11/2025
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Resident Records/Incident Reports: Ten resident files were reviewed. Appraisals and physician's reports were observed conducted within the last 12 months. Bed rails request were reviewed for each half/full bed rail observed. However, there were (3) residents observed with full bed rails and physician's request were observed but residents are not on hospice care.
Disaster Preparedness: Emergency Disaster plan was reviewed and last reviewed on 3/1/24. Last emergency drill was conducted on 3/5/25. LPA observed an evacuation chair on top of each stairwell.
Residents with Special Health Needs: Hospice plans were reviewed for pertaining residents. Staff have received training on Hospice care, Restricted Health conditions, Postural support and Dementia.

A deficiency was noted today per Title 22 Regulations.

Exit interview was conducted with Virginia Garcia and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/11/2025 04:44 PM - It Cannot Be Edited


Created By: Mary G Flores On 03/11/2025 at 04:30 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: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
87608 Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, ... (5) Under no circumstances shall postural supports.... (B)Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 3 out of 10 residents have a full bed rail on their beds and a full bed rail physician's order and are not under hospice care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2025
Plan of Correction
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Administrator will communicate with physician and ensure that the resident requires a full bed rail and will either change bed rail to half bed rail or will submit a postural support exception request to the department for each resident listed on LIC 811 and will submit new orders and pictures of bed rails or the exceptions by POC due date 3/18/25.
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:Tony Vasallo
LICENSING EVALUATOR NAME:Mary G Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2025


LIC809 (FAS) - (06/04)
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