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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208773
Report Date: 04/26/2023
Date Signed: 04/26/2023 07:53:43 PM


Document Has Been Signed on 04/26/2023 07:53 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: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: 80DATE:
04/26/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:23 PM
MET WITH:Administrator Ramona ElecoTIME COMPLETED:
05:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Shawna Doucette went to the facility unannounced to conduct a 10 day complaint investigation, where other deficiencies were observed during the course of the investigation. LPA conducted a case management to address the deficiencies. LPA met with Administrator Ramona Eleco.

LPA reviewed R1's file. LPA interviewed Administrator Ramona Eleco. LPA requested copies of all incident reports from 1/1/23 until 4/19/23 for R1's hospitalization. Administrator was able to provide an incident report for 1/29/23 but was not able to provide incident reports for 2/24/23, 3/18/23 or 4/18/23.

LPA requested copies of staff training for R1's restricted health condition. Administrator was unable to provide copies of training for R1's restricted health condition. LPA requested copies of home health records. Administrator contacted home health and requested the records of care for R1. Administrator was only able to provide dates home health came to the facility to care for R1 and was unable to provide any further information.

The above deficiencies were cited per California Code of Regulations, Title 22, Division 6, Chapter 8, on attached 809D.

An exit interview was conducted with the Administrator and a copy of this report, plan of correction with appeal rights was provided to Administrator Ramona Eleco.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 04/26/2023 07:53 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: JASMIN TERRACE AT BAKERSFIELD
FACILITY NUMBER: 157208773

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/08/2023
Section Cited

1
2
3
4
5
6
7

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1)A written report shall be submitted to the licensing agency and to the person responsible for the resident
1
2
3
4
5
6
7
Plan of Correction POC LIcensee agrees to submit in writing the understanding of this regulation and how the regulation will be met by POC due date 05/08/23.
8
9
10
11
12
13
14
within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not met as evidenced by Licensee did not submit incident reports for R1's hospitalization on 2/24/23, 3/18/23 and 4/18/23 which poses a potential Health, Safety or personal rights risk to the residents in care.
8
9
10
11
12
13
14
Type B
05/12/2023
Section Cited

1
2
3
4
5
6
7
87613 General Requirements for Restricted Health Conditions (a) Prior to admission of a resident with a restricted health condition, the licensee shall: (2) Ensure that facility staff who will participate in meeting the resident’s specialized care needs complete training provided by a licensed professional sufficient to meet those needs. (A) Training shall include hands-on instruction in both general procedures and resident-specific procedures (B)Training shall be completed prior to the staff providing services to the resident.This requirement was not met as evidenced by: Licensee
1
2
3
4
5
6
7
Plan of Correction POC Licensee agrees to have staff trained for the care of R1's restricted health condition by a licensed professional. Licensee agrees to submit documentation of training by the licensed professional, a roster of staff trained, and the responsibilities of staff for R1's retricted health condition by POC due date 5/12/23
8
9
10
11
12
13
14
did not have staff trained by a licensed professional to care for R1's restricted health condition which poses a potential Health, Safety or personal rights risk to the residents in care.
8
9
10
11
12
13
14
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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Shawna DoucetteTELEPHONE: (559) 580-4595
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2