197606832-6-9-2021-31-AS-JGTN-C3TUAL-20210609152456

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606832
Report Date: 06/09/2021
Date Signed: 06/09/2021 03:25:03 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	JAZMIN HOME FOR THE ELDERLY		FACILITY NUMBER:	197606832
ADMINISTRATOR:	EVANGELINE BOOT		FACILITY TYPE:	740
ADDRESS:	4425 VERDUGO ROAD		TELEPHONE:	(323) 799-1113
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90065
CAPACITY:	6	CENSUS: 6	DATE:	06/09/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:25 AM
MET WITH:	Evangeline Booth - Administrator		TIME COMPLETED:	01:45 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 Analysts (LPAs) Gary Tan, LaQueena Lacy and Rosaura Valenzuela conducted an unannounced Required One (1) year - Infection Control inspection to the facility. LPAs met with the Administrator Evangeline Boot and explained the reason for the visit. A tour of the physical plant was conducted at 11:30 AM and the following was noted: There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPAs were screened upon entry. All staff were observed to be wearing mask upon entrance and during visit. The facility had submitted and approved Mitigation plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the front and backyard. The facility has sufficient stock of PPE in the storage room. The facility has six (6) bedrooms and two (2) bathrooms currently occupying six (6) residents. One (1) bedroom is designated for staff use. The facility is fire cleared for four (4) non-ambulatory residents, hospice waiver for four (4). (continued on LIC 809-C)

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: JAZMIN HOME FOR THE ELDERLY	FACILITY NUMBER: 197606832
	VISIT DATE: 06/09/2021

NARRATIVE

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(continued on LIC 809-C)

Living and dining room furniture were also checked. The living room is neat and clean along with the family room. The facility maintains a comfortable temperature at 73°F. The smoke detectors are hardwired and interconnected and observed to be operational. There is a carbon monoxide installed at the facility. Fire extinguishers are located in the kitchen and the living room and were observed to be full and last inspected on 12/14/20.
The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water at the facility. There is also a locked shed at the backyard being used as a used equipment storage.
The garage is attached to the facility and currently being used as perishable and emergency food, PPE supplies and used equipment storage. Laundry room is located adjacent to the kitchen, laundry detergents, cleaning agents and other toxins are stored in a cabinet in the laundry area which was observed to be unlocked. Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee.

Staff Rooms: No medications are observed in the staff room.

The bathroom were checked for cleanliness and proper operation. LPAs observed the appropriate grab bars in the toilet and shower. The hot water temperature was measured a range of 115.5°F to 118.4°F. Towels and washcloths are not shared. There was enough clean linen available in stock at the cabinet.

Medications: LPAs observed medication in the kitchen cabinet to be locked and inaccessible to residents. There were two (2) complete first aid kits located at the medication cabinet.

Citation issued. Appeal rights discussed and given. Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: JAZMIN HOME FOR THE ELDERLY	FACILITY NUMBER: 197606832
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/09/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation during the physical plant tour, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/09/2021
	Plan of Correction
1 2 3 4	Staff immediately kept the laundry detergent and other chemicals in a locked area. Cleared during visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2021

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2021

LIC809 (FAS) - (06/04)

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