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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157208773
Report Date: 12/01/2020
Date Signed: 12/01/2020 10:13:24 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/05/2020 and conducted by Evaluator See Moua
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20201005100629
FACILITY NAME:JASMIN TERRACE AT BAKERSFIELDFACILITY NUMBER:
157208773
ADMINISTRATOR:KIRK, ELIZABETHFACILITY TYPE:
740
ADDRESS:5400 STINE ROADTELEPHONE:
(661) 398-8802
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY:99CENSUS: 64DATE:
12/01/2020
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Interim Administrator Ramona "Mona" DeposaTIME COMPLETED:
08:16 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained injuries while in care.
Staff did not ensure resident was provided with adequate bedding.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) S. Moua called and spoke with Interim Administrator Mona regarding the complaint allegations. Findings were delivered over the phone due to COVID 19 precautionary guidelines.

The Department interviewed staff and R1 referenced directly in the complaint. R1 confirmed that she has a bed and pillow. She clarified that what she wanted was a hospital bed, which the facility has worked on obtaining a prescription for. R1 also confirmed that she does not have weeping or open wounds on her legs. Records reviewed documented that the facility scheduled a doctor’s visit to obtain a hospital bed and new wheelchair for R1 a week after she was admitted. The above allegations are Unfounded.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: See MouaTELEPHONE: (559) 650-7904
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/05/2020 and conducted by Evaluator See Moua
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20201005100629

FACILITY NAME:JASMIN TERRACE AT BAKERSFIELDFACILITY NUMBER:
157208773
ADMINISTRATOR:KIRK, ELIZABETHFACILITY TYPE:
740
ADDRESS:5400 STINE ROADTELEPHONE:
(661) 398-8802
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY:99CENSUS: 64DATE:
12/01/2020
UNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Interim Administrator Ramona "Mona" DeposaTIME COMPLETED:
08:16 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff stole resident's personal belongings.
Resident's needs are not being met.
Staff did not ensure resident received medications.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) S. Moua called and spoke with Interim Administrator Mona regarding the complaint allegations. Findings were delivered over the phone due to COVID 19 precautionary guidelines.

The Department interviewed staff and R1 referenced directly in the complaint. Per interviews conducted, R1 has chosen to be in charge of scheduling her own doctor’s appointments and picking up certain medications. R1 did not have any issues with her personal belongings being stolen and did not specify what was taken. R1 expressed that she wanted to remain at a Skilled Nursing Facility and desires to go back to SNF. Facility staff interviewed denied the allegations that R1’s needs are not being met, that she did not receive her medications, or that her belongings were stolen. There is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are Unsubstantiated. Exit Interview was conducted.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: See MouaTELEPHONE: (559) 650-7904
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2