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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306001102
Report Date: 02/23/2022
Date Signed: 02/23/2022 04:57:44 PM

Document Has Been Signed on 02/23/2022 04:57 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:JASMIN'S CARE HOMEFACILITY NUMBER:
306001102
ADMINISTRATOR:MANUEL G. PEREZFACILITY TYPE:
740
ADDRESS:2817 SAN JUAN LANETELEPHONE:
(714) 662-0625
CITY:COSTA MESASTATE: CAZIP CODE:
92626
CAPACITY: 6CENSUS: 5DATE:
02/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:38 PM
MET WITH:Manuel Perez - AdministratorTIME COMPLETED:
05:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Patricia Velazquez conducted an unannounced visit to Jasmin's Care Home. The purpose of today's visit was to conduct a Required 1 Year inspection. LPA Velazquez was allowed entry into the facility and met with Caregiver Laura Perdomo. Administrator (AD) Manuel Perez arrived shortly after LPA's arrival. The facility is licensed for 6 non-ambulatory residents. There are currently 5 residents living in the facility. The last emergency disaster drill was conducted on April 3, 2021.

At 2:53 PM LPA Velazquez conducted a tour of the physical plant along with AD Perez. The 1 story home consists of 4 resident bedrooms with 2 bathrooms. There are no staff bedrooms as AD Perez indicated he employs awake staff at night from 10:00 PM to 7:00 AM. The facility also has a living room, dining area, and kitchen. LPA and AD observed 4 bottles of medications were stored on top of a cabinet in the dining room easily accessible to residents. Two of the 4 bottles had prescription Amlodipine Besylate belonging to a resident which AD verified. At LPA's direction AD immediately removed the medications and locked them in the medication cabinet. The 5 residents in the facility appeared well-groomed and well cared-for. The resident bedrooms had the required furnishings, bed linens, and closet/drawer space to accommodate each resident comfortably. LPA Velazquez observed a postural support bar on one of the resident beds. AD Perez indicated he did not have a written physician's order for the postural support bar. LPA and AD observed an exit door in a resident's room did not have an auditory alarm and the facility has residents with Dementia. AD verified the sliding glass door did not have an auditory alarm pursuant to Title 22 regulation. The sliding glass in the living room also had an inoperable auditory alarm which AD verified. Resident bath towels and personal hygiene supplies were adequately stocked. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, showers were free of mold/mildew and a non-skid surface or mat was in place. LPA Velazquez tested the hot water temperature in the resident bathrooms and the temperature measured at 109.0 degrees Fahrenheit in the first bathroom and at 115.3 degrees Fahrenheit in the left sink and at 114.0 degrees Fahrenheit in the right sink of the second bathroom.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE: DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: JASMIN'S CARE HOME
FACILITY NUMBER: 306001102
VISIT DATE: 02/23/2022
NARRATIVE
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LPA Velazquez inspected the kitchen along with AD Perez. LPA and AD observed the right front burner of the electric stove was inoperable which AD verified. Perishable and non-perishable food supply was checked and adequately stocked at the time of the visit. The fire extinguisher was fully charged. The smoke and carbon monoxide detectors were tested and found to be operational. Toxins and sharps were locked and inaccessible to residents. First aid kit was checked and found to be in order. The facility did have a First Aid guide dated 1989 and LPA Velazquez advised AD Perez to obtain an updated First Aid manual.

LPA Velazquez along with AD Perez toured the outside grounds and observed a jacuzzi that was surrounded by a locked gate. LPA and AD observed the jacuzzi had standing water which AD indicated was from the recent rains. AD indicated he would empty out the jacuzzi by tomorrow. There was shading and sufficient seating for residents. LPA and AD also observed the umbrella that provides shading had a large tear which AD verified. AD indicated he had already order another umbrella and will email LPA a copy of the receipt by tomorrow. LPA and AD also observed broken wooden fencing and a worn wooden bench. AD indicated he would remove the wooden bench and repair the wooden gate enclosure. AD indicated he an insurance claim that is pending. There was also a large rusted metal pole with rusted screws protruding from the pole which AD verified. Walkways around the home were clear of hazards and the exit gates were operational. There were no security bars or weapons on the premises.

No resident or staff files were reviewed at the time of this visit but LPA did verify 2 of the 5 residents in the facility were diagnosed with Dementia which AD verified. LPA Velazquez informed AD Perez to ensure a written physician's order for bed rails is present in a resident's file pursuant to Title 22 Regulation Section 87608 Postural Supports


Deficiencies cited under California Code of Regulations Title 22, Division 6, Chapter 8. An exit interview was conducted with Administrator Manuel Perez and a copy of this report along with the appeal rights and a copy of the LIC 9098 were provided at the time of this visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022
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Document Has Been Signed on 02/23/2022 04:57 PM - It Cannot Be Edited


Created By: Patricia Velazquez On 02/23/2022 at 04:08 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: JASMIN'S CARE HOME
FACILITY NUMBER: 306001102

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)

87465(h)(2) Incidental Medical and Dental Care. The follwoing requirements shall apply to medications which are centrally stored: Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as 2 prescription medication bottles were stored on top of the medication cabinet easily accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2022
Plan of Correction
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Licensee shall ensure that all medications are properly locked and inaccessible to residents at all times. Licensee shall provide staff training on proper medication storage and submit written proof to LPA by POC due date.
Type A
Section Cited
CCR
87705(j)
87705(j) Care of Persons with Dementia. The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard for any resident.

Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 2 out of 3 exit doors which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/23/2022
Plan of Correction
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Licensee to repair or replace the inoperable auditory alarms and submit written proof to LPA by POC due date.
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:Sheila Santos
LICENSING EVALUATOR NAME:Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2022


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Document Has Been Signed on 02/23/2022 04:57 PM - It Cannot Be Edited


Created By: Patricia Velazquez On 02/23/2022 at 04:29 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
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: JASMIN'S CARE HOME
FACILITY NUMBER: 306001102

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(32)

87555(b)(32) General Food Service Requirements. The following food service requirements shall apply: Equipment or appropriate size and type shall be provided for the storage, preparation, and service of food and for sanitizing utensils and table shall be well maintained.
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 1 out of 4 stove top burners which poses/posed a potential health, safety or personal rights risk to persons in care. The right front stove top burner was inoperable.
POC Due Date: 03/02/2022
Plan of Correction
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Licensee to ensure all the stove top burners are in operating condition at all times and submit written proof to LPA by POC due date.
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:Sheila Santos
LICENSING EVALUATOR NAME:Patricia Velazquez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2022


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