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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157206768
Report Date: 03/11/2024
Date Signed: 03/11/2024 01:57:27 PM


Document Has Been Signed on 03/11/2024 01:57 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, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:JASMINE GARDEN RESIDENTIAL CARE IIFACILITY NUMBER:
157206768
ADMINISTRATOR:BARCELONA, NELIAFACILITY TYPE:
740
ADDRESS:14012 TOLUCA DRIVETELEPHONE:
(661) 829-6818
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93314
CAPACITY:6CENSUS: 4DATE:
03/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Administrator, Nelia Barcelona and Licensee, Marc BarcelonaTIME COMPLETED:
01:39 PM
NARRATIVE
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On 03/11/2024, 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. LPA met with Administrator, Nelia Barcelona.

LPA conducted a tour inside and outside of facility. Facility observed to be clean, odor free and at a comfortable temperature. Common areas were furnished well with adequate seating and lighting available. Resident rooms appeared clean and had required furnishings. Resident bathrooms were properly equipped with securely fastened grab bars in toilet and tub/shower areas, non-skid mats were observed. Hot water measured at 109.7 degrees F. Kitchen toured. Kitchen appeared clean, LPA observed an adequate food supply. 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 1/22/2024.

LPA reviewed staff and resident records. Upon review of resident records, LPA observed that 3 out of 4 residents did not have an updated needs and services/care plan. Medications reviewed. LPA observed that two medications for R3 had altered labels. Per Administrator, R3's family altered the label. The instructions on the label did not match the medication record on file.

Deficiencies are being issued 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, Nelia 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 03/25/2024: 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: 03/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2024
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 03/11/2024 01:57 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 II
FACILITY NUMBER: 157206768

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(1)
Incidental Medical and Dental Care Services
(1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when 3 out of 4 residents did not have a needs and services/care plan of care which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Licensee agreed to develop a needs and services/ care plan for 3 out of 4 residents and submit the plan to the Fresno CCL office by the POC due date.
Type B
Section Cited
CCR
87465(h)(4)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws. No persons other than the dispensing pharmacist shall alter a prescription label.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above when 1 out of 4 residents had altered medication labels, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Licensee agrees to review section 87465 and submit a written statement detailing the steps the facility will take to ensure that no persons other than the dispensing pharmacist will alter a resident's medication prescription label.
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: 03/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2024
LIC809 (FAS) - (06/04)
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