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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015600229
Report Date: 10/11/2024
Date Signed: 10/11/2024 02:30:45 PM

Document Has Been Signed on 10/11/2024 02:30 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:
10/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH: Administrator, Tracy Mitchell TIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On 10/11/24 at 2:30 p.m., Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct a case management visit due to receiving complaint #15-AS-20241001091419. LPA met with Administrator, Tracy Mitchell and explained the purpose of the visit.

During the visit LPA toured the facility and interviewed S1.

THE FOLLOWING DEFICIENCY WAS OBSERVED:
LPA observed the first floor of the facility was under construction.

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: 10/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 10/11/2024 02:30 PM - It Cannot Be Edited


Created By: Gregory Clark On 10/08/2024 at 03:13 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/15/2024
Section Cited
CCR
80061(e)(4)

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80061 Reporting Requirements
(e) The items below shall be reported to the licensing agency within 10 working days following the occurrence.
(4) Any changes in the plan of operation which affect the services to clients.

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ADM to review regulation and send LPA proof by POC date.
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This requirement is not met as evidenced by:
ADM failed to notify CCL of construction work 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: 10/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2024


LIC809 (FAS) - (06/04)
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