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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606644
Report Date: 05/14/2022
Date Signed: 05/14/2022 02:48:16 PM


Document Has Been Signed on 05/14/2022 02:48 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:JASMINE'S HOME CAREFACILITY NUMBER:
197606644
ADMINISTRATOR:LEVITA H. MAGHIRANGFACILITY TYPE:
740
ADDRESS:13829 E. RUSSELL STREETTELEPHONE:
(562) 693-9608
CITY:WHITTIERSTATE: CAZIP CODE:
90605
CAPACITY:6CENSUS: 4DATE:
05/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Levita MaghrangTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angelica Rea conducted an unannounced visit for the purpose of conducting the required annual inspection. On today's visit LPA met with Caregiver, Vicky Fallaria who allowed entry into the facility. Administrator, Levita Maghrang arrived at the facility a short time later.

LPA discussed infection control practices with Ms. Maghrang, toured the facility inside and out, reviewed food supply, reviewed staff files, and reviewed resident medications.

Bedrooms have the required furniture including bedframes, dressers, lamps and chairs. Beds have the required linen and the linen is in good condition. Passageways and exits are free of obstruction. The front and backyard are well maintained. The resident bathrooms are clean, and showers have non-skid materials. The hot water temperature measured at 134.4 degrees F in bathroom #1, and 137.1 degrees F in bathroom #2. The facility temperature at the time the visit was comfortable. There is sufficient lighting throughout the facility. There are smoke detectors located throughout the facility, tested and operational. Carbon monoxide detector was also observed, tested and operational. LPA observed a sufficient supply of PPE. Infection control signs were observed throughout the facility.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were deficiencies observed during the visit. Exit interview held and a copy of the report and appeal rights were provided to Ms. Maghrang.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2022
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 05/14/2022 02:48 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: JASMINE'S HOME CARE
FACILITY NUMBER: 197606644

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)


This requirement is not met as evidenced by: LPA observed water temperature measured at 134.4 degrees Fahrenheit in bathroom #1 and 137.1 degrees Fahrenheit in bathroom #2.
Deficient Practice Statement
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Based on observation, the administrator did not comply with the section cited above in 2 out of 2 bathrooms, which poses an immediate health and safety risk to persons in care.
POC Due Date: 05/18/2022
Plan of Correction
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Administrator will ensure that water temperature measures between 105 degrees and 120 degrees Fahrenheit as required. Administrator will send LPA a log with water temperature readinsg for 3 days by POC due date.
Type A
Section Cited
CCR
87465(a)(4)


This requirement is not met as evidenced by: LPA observed that Resident #1's Senna 8.6 mg medication dated 4/20/22 has not been administered. The medication states that is is to be given daily.
Deficient Practice Statement
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Based on observation, the administrator did not comply with section cited above which poses an immediate health and safety risk to personsl in care.

POC Due Date: 05/18/2022
Plan of Correction
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Administrator will ensure that all medication is administered as required. Administrator will provide proof of medication training to Staff by POC due date.

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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:
DATE: 05/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2022
LIC809 (FAS) - (06/04)
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