197606832-12-2-2023-31-AS-EDAT-CY5S55-20231202123345

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606832
Report Date: 12/02/2023
Date Signed: 12/02/2023 12:34:42 PM

Document Has Been Signed on 12/02/2023 12:34 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
Lookup Error,
, CA

FACILITY NAME:	JAZMIN HOME FOR THE ELDERLY		FACILITY NUMBER:	197606832
ADMINISTRATOR:	EVANGELINE BOOT		FACILITY TYPE:	740
ADDRESS:	4425 VERDUGO ROAD		TELEPHONE:	(323) 255-5703
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90065
CAPACITY:	6	CENSUS: 5	DATE:	12/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:57 AM
MET WITH:	Evangline Booth		TIME COMPLETED:	12:47 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	On 12/02/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with care staff Esther Lim and explained the purpose of today’s visit. Lim contacted the administrator Evangeline Booth. The facility is licensed to operate for six (6) of (4) may be non-ambulatory elderly residents. The facility is approved for (4) hospice residents. Currently, the facility has (3) residents in hospice care. The facility is a single-story structure located in a residential neighborhood. It consists of the following: five (5) resident's rooms, two (2) common bathrooms, a living area, a dining area, a kitchen, and an outside covered patio area. LPA and administrator toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were operational. The water temperature measured 116.0 degree F. A comfortable temperature of 70 degree was maintained in the facility. LPA observed the facility to be clean and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Fire extinguishers were charged, smoke detectors and carbon monoxide were operable. A review of the Medication Administration Record (MAR) was complete and accurate. The facility has conducted a disaster drill on 08/01/23. A landline telephone was in working condition. A review of staff CPR/First Aid training is current. Evaluation Report Continues LIC 809-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) -98-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2023

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
Lookup Error,
, CA

FACILITY NAME: JAZMIN HOME FOR THE ELDERLY	FACILITY NUMBER: 197606832
	VISIT DATE: 12/02/2023

NARRATIVE

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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. The facility has current liability insurance on file effective 07/06/23 through 07/06/24. The facility is current on Community Care Licensing annual dues.

An audit of residents #1-#5 (R1-R5) service files and staff #1-#6 (S1-S6) personnel files revealed to be complete. Interviews conducted with (5) residents and (6) staff were completed.

No deficiencies cite during this visit.

An exit interview was conducted with Evangeline Booth, and a copy of the report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) -98-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2023

LIC809 (FAS) - (06/04)

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