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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202402
Report Date: 12/10/2021
Date Signed: 12/13/2021 09:20:28 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:JASMINE GARDEN RESIDENTIAL CAREFACILITY NUMBER:
157202402
ADMINISTRATOR:BARCELONA, MARC OR NELIAFACILITY TYPE:
740
ADDRESS:14016 TOLUCA DRIVETELEPHONE:
(661) 410-8297
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY:6CENSUS: 4DATE:
12/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Marc Barcelona and Administrator Nelia Barcelona TIME COMPLETED:
12:00 PM
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Licensing Program Analyst LPA Shawna Doucette conducted an Annual Inspection on this date. LPA was met by Staff Dominga Villegas and discussed the purpose of the visit. Administrator Marc Barcelona and Administrator Nelia Barcelona responded to the facility to assist with the inspection. LPA and Administrator Marc Barcelona and Administrator Nelia Barcelona began the tour at the front entrance of the facility.

Visitor log-in/temperature check, masks, and disinfection station was observed upon entry. Facility has one entrance/exit point. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common areas. Hand washing and other various Covid-19 related signs were observed in the common areas.

LPA observed a two day supply of perishable food and seven day supply of non-perishable food. Cleaning supplies were observed behind a locked door in laundry room. LPA observed the following personal protective equipment in a storage cabinet; gowns, face shield, gloves, and masks. Staff records were reviewed for infection control training. LPA observed all facility staff wearing masks. Resident’s files have updated emergency contact information.

No deficiencies were observed.

Exit interview was conducted and a copy of this report was provided via email.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
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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