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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208773
Report Date: 06/18/2024
Date Signed: 06/18/2024 09:30:10 PM


Document Has Been Signed on 06/18/2024 09:30 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
SIERRA CASCADE AC/SC, 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: 76DATE:
06/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:07 PM
MET WITH:Administrator Ramona ElecoTIME COMPLETED:
09:45 PM
NARRATIVE
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On 6/18/2024 Licensing Program Analysts (LPAs) B. Miranda & S. Doucette arrived to the facility unannounced. During the visit LPAs spoke with various residents at the facility.

R1 had a black eye. When LPA asked how R1 got the black eye they stated they fell. Administrator stated R1 fell on 6/17/24, facility was informed there is still time to report.

R2 had injuries to their legs. R2 stated they crashed into the vending machine about a week and a half ago. Administrator stated the incident happened about 1-2 weeks ago.

LPA S. Doucette conducted interviews and was informed R3 was placed in the Geri Chair after eloping from the facility. Administrator was asked about the elopement and stated R3 followed their son out of the facility, and the son and had to bring R3 back to the facility. Facility had their own incident report, but the incident was not provided to the Dept. The facility's report states the resident was found at a neighbor's house. LIC602 indicated the R3 cannot leave the facility unattended. Copy of facility report was provided to LPA. Citation and civil penalty will be issued. LPA asked Administrator if they knew which exit R3 left the facility, Administrator stated they believe through the front door, the front door does not have an auditory device. LPA S. Doucette cited for no auditory device on the front door for the annual inspection.

While touring the facility LPAs observed R4 to have long and black/brown toe nails. The nails on the big toes are longer than the tip of the big toe (pictures were taken). Administrator was asked why R4's toe nails were so long, Administrator stated maybe because of their diabetic shoes. LPA asked if R4 sees a podiatrist, Administrator stated when needed. LPA showed Administrator the picture, administrator had no comment.

Citations were issued under Title 22, Division 6, & Chapter 8 on LIC809D & civil penalties were issued.

Exit interview was conducted and a copy of this report was provided to Administrator Ramona Eleco.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024
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 3


Document Has Been Signed on 06/18/2024 09:30 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: JASMIN TERRACE AT BAKERSFIELD
FACILITY NUMBER: 157208773

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/28/2024
Section Cited
CCR
87211(a)(1)

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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 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 is not met as evidenced by:
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Procedure will be put into place to make sure all incidents are reported to the Dept within the proper time limit.
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Based on observation, interview, & record review the licensee failed to report 3 incidents to the Dept that occurred in the facility. R3 eloped from the facility and it was not reported to the Dept.
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Type B
06/28/2024
Section Cited
CCR87465(a)(1)

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87465 Incidental Medical and Dental Care. (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(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:
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Frequent body check on R4. Administrator will make arrangement with R4's doctor.
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Based on observation, interview, & record review the licensee failed to arrange or assist R4 with proper foot care.
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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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/18/2024 09:30 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: JASMIN TERRACE AT BAKERSFIELD
FACILITY NUMBER: 157208773

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/19/2024
Section Cited
CCR
87464(f)(1)

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87464 Basic Services
(f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c). Health and Safety Code section 1569.2(c) provides:
(c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered. Assistance includes assistance with taking medications, money management, or personal care.
This requirement is not met as evidenced by:
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R3 has been placed on special monitoring. Statement will be sent to LPA.
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Based on observation, interview, and record review the licensee failed to follow physician orders by allowing the resident to elope from the facility unassisted. Facility did not know R3 left until R3's family arrived and was unable to locate R3 at the facility.
This poses an immediate health, safety, or personal rights risk to residents in care.
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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: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Brianna MirandaTELEPHONE: 559-770-0254
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3