<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 157208773
Report Date: 11/22/2021
Date Signed: 11/22/2021 05:52:16 PM

Substantiated


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
04/13/2021 and conducted by Evaluator Kelly J. McClurg
COMPLAINT CONTROL NUMBER: 24-AS-20210413092742
FACILITY NAME:JASMIN TERRACE AT BAKERSFIELDFACILITY NUMBER:
157208773
ADMINISTRATOR:ELECO, RAMONA D.FACILITY TYPE:
740
ADDRESS:5400 STINE ROADTELEPHONE:
(661) 398-8802
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY:99CENSUS: 79DATE:
11/22/2021
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator Ramona ElecoTIME COMPLETED:
06:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not following licensed physicians orders as prescribed

INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
An unannounced Complaint visit was conducted on the date & during the times identified above by Licensing Program Analyst (LPA) K. McClurg & Licensing Program Manager (LPM) See Moua. LPA & LPM met with Administrator (Admin) Ramona Eleco & stated purpose of visit.

Resident MARs & Centrally Stored Medication & Destruction Record (CSMDR) reviewed for Resident 1 (R1) & random resident records. MARS not appropriately maintained - no initials that AM medications had been given. CSMDR did not reflect all medications on premises &/or medication was listed on CSMDR & medication not available for review.

The Department has investigated the above allegation & has found it to be Substantiated.

Deficiencies Issued
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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 3
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
04/13/2021 and conducted by Evaluator Kelly J. McClurg
COMPLAINT CONTROL NUMBER: 24-AS-20210413092742

FACILITY NAME:JASMIN TERRACE AT BAKERSFIELDFACILITY NUMBER:
157208773
ADMINISTRATOR:ELECO, RAMONA D.FACILITY TYPE:
740
ADDRESS:5400 STINE ROADTELEPHONE:
(661) 398-8802
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93313
CAPACITY:99CENSUS: 79DATE:
11/22/2021
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Administrator Ramona ElecoTIME COMPLETED:
06:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident wheelchair is in disrepair
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
R1 currently has operational wheelchair & power wheelchair. Admin interviewed & stated that additional wheelchairs are available for use in any interim when resident is waiting waiting for new/upgraded wheelchair.

The Department has investigated the above allegation & determined it to be Unsubstantiated.

Exit interview conducted with Admin. Report Provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
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 3
Control Number 24-AS-20210413092742
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: JASMIN TERRACE AT BAKERSFIELD
FACILITY NUMBER: 157208773
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/23/2021
Section Cited
CCR
87465(a)(5)
1
2
3
4
5
6
7
Incidental Medical and Dental Care-The licensee shall assist residents with self-administered medications as needed.
1
2
3
4
5
6
7
Admin to submit plan by due date that outlined a plan with dates on how issue will be corrected, including staff training.
8
9
10
11
12
13
14
MARS observed not maintained ensuring that residents are receiving assistance with rx as needed.
8
9
10
11
12
13
14
Type A
11/23/2021
Section Cited
CCR
87645(h)(2)
1
2
3
4
5
6
7
Incidental Medical and Dental Care-Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.
1
2
3
4
5
6
7
Admin to remove all items that should be centrally stored from R1's room.
Admin to submit plan by due date that outlined a plan with
8
9
10
11
12
13
14
Variety of unidentified medications & vitamins observed in R1's room - not centrally stored or maintained in a locked location
8
9
10
11
12
13
14
 dates on how issue will be corrected, including staff training.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: Kelly J. McClurg
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3