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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157202402
Report Date: 12/18/2023
Date Signed: 12/18/2023 12:00:00 PM


Document Has Been Signed on 12/18/2023 12:00 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, 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:
12/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Administrator, Marc BarcelonaTIME COMPLETED:
12:08 PM
NARRATIVE
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On 12/18/2023, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct an annual inspection. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. Facility staff granted LPA entry to the facility and contact the Administrator via telephone. Administrator, Marc Barcelona, arrived a short time later.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Resident rooms appeared clean and had required furnishings. LPA observed an adequate supply of linen. Resident bathrooms were properly equipped with securely fastened grab bars in toilet and tub/shower areas, non-skid mats were observed. LPA observed that the tub faucet was leaking, facility placed a large bucket under the faucet. Hot water measured at 122.7 degrees F. Kitchen toured, appeared clean, observed a 7-day supply of non-perishable and 2-day supply of perishable food. LPA observed Clorox wipes accessible to residents in care and the stove knobs were not removed when the stove was not in operation. Exterior tour conducted, all exits open and free of obstructions. Side gate was observed to be self-latching.

Fire extinguisher serviced on 03/20/2023. Smoke detectors and carbon monoxide detectors observed operational during today’s inspection. Last fire drill conducted on 10/25/2023. LPA reviewed staff and client records. Medications reviewed and observed to have original labels and be administered as prescribed. Medications were observed to be accessible to residents in care due to the lock on the cabinet needing to be repaired. LPA observed multiple pills/tablets in a zip lock bag in the medication cabinet as well as 3 prescription bottles that contained discontinued medication. Administrator stated that medications are in the cabinet due to needing to be destroyed.

Deficiencies are being cited in accordance to California Code of Regulations, Title 22, Division 6 on the attached 809D. Exit interview conducted and a plan of correction was reviewed and developed with Administrator. A copy of this report and appeal rights were discussed and provided to Administrator, Marc Barcelona, whose signature on this form confirms receipt of this document.

LPA is requesting the following documents be submitted to the Fresno CCL office by 01/08/2024: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E) Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A), Surety Bond*

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2023
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 12/18/2023 12:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: JASMINE GARDEN RESIDENTIAL CARE
FACILITY NUMBER: 157202402

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation], the licensee did not comply with the section cited above in when the hot water in the resident bathroom measured at 122.7 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2023
Plan of Correction
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Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements for section 87303 are met by the POC due date. Licensee also agreed to measure water daily for 7 days and documents the water temperature. Licensee will submit the water log to the Fresno CCL office by 12/27/2023.
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in when medications were accessible to residents in care when the cabinet locking mechanism was in disrepair and the clorox wipes were accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2023
Plan of Correction
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Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements for the above section are met to the Fresno CCL office. The written statement shall include the Licensee's plan to repair the medication cabinet locking mechanism.
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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2023
LIC809 (FAS) - (06/04)
Page: 2 of 7


Document Has Been Signed on 12/18/2023 12:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: JASMINE GARDEN RESIDENTIAL CARE
FACILITY NUMBER: 157202402

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in when the tub faucet was in need of repair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/11/2024
Plan of Correction
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Licensee agrees to repair the tub faucet and submit proof of repair to the Fresno CCL office by the POC due date.
Section Cited
Maintenance and Operation
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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2023
LIC809 (FAS) - (06/04)
Page: 3 of 7


Document Has Been Signed on 12/18/2023 12:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: JASMINE GARDEN RESIDENTIAL CARE
FACILITY NUMBER: 157202402

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(d)
(d) In addition to requirements specified in Section 87303, Maintenance and Operation, safety modifications shall include, but not be limited to, inaccessibility of ranges, heaters, wood stoves, inserts, and other heating devices to residents with dementia

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when the facility did not remove the stove knobs when the stove was not being operated which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2023
Plan of Correction
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Licensee agrees to review section 87705 and submit a written statement detialing the steps the facility will take to ensure the requirement for section 87705 are met to the Fresno CCL office by the POC due date.
Type A
Section Cited
CCR
87465(i)
(i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when LPA observed multiple pills/tablets that required disposal and/or destruction and were stored in the medication cabinet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2023
Plan of Correction
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Licensee agrees to review section 87465 and submit a written statement detaling the steps the facility will take to ensure the requirements for section 87465 are met to the Fresno CCL office by the POC due date. Facility's plan should include the date and time when the medications were destroyed.
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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:
DATE: 12/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2023
LIC809 (FAS) - (06/04)
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