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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600229
Report Date: 08/23/2024
Date Signed: 08/23/2024 03:50:15 PM

Document Has Been Signed on 08/23/2024 03:50 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, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:JASMINE'S CARE HOMEFACILITY NUMBER:
015600229
ADMINISTRATOR/
DIRECTOR:		MITCHELL, TRACYFACILITY TYPE:
735
ADDRESS:1042A CALCOT PLACETELEPHONE:
(510) 532-4556
CITY:OAKLANDSTATE: CAZIP CODE:
94606
CAPACITY: 8CENSUS: 1DATE:
08/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Tracy Mitchell, LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 8/23/24 at 3:30 PM, Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct Case Management - Deficiencies visit. LPA met with Licensee, Tracy Mitchell and explained the purpose of the visit.

THE FOLLOWING DEFICIENCY WAS OBSERVED:
ยท During the annual inspection on 6/06/24 it was discovered that the facility did not have an certified administrator from May 2023 until the present time.

The above deficiency was observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiency by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator. LIC809D, Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Gregory Clark
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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 08/23/2024 03:50 PM - It Cannot Be Edited


Created By: Gregory Clark On 08/23/2024 at 11:24 AM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: JASMINE'S CARE HOME
FACILITY NUMBER: 015600229

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/28/2024
Section Cited
CCR
85064(b)

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(b) All adult residential facilities shall have a qualified and currently certified administrator.
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The licensee will implement a plan to hire a new administrator and submit plan to CCLD by POC date.
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Based on record review, the licensee did not comply with the section cited above. There is no certified administrator employed at the facility which poses a potential health, safety or personal rights risk to 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:Yvonne Flores-Larios
LICENSING EVALUATOR NAME:Gregory Clark
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024


LIC809 (FAS) - (06/04)
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