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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607655
Report Date: 11/23/2020
Date Signed: 01/13/2021 09:30:22 AM

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:JASMIN TERRACE AT EL MOLINOFACILITY NUMBER:
197607655
ADMINISTRATOR:VIRGINIA GARCIAFACILITY TYPE:
740
ADDRESS:245 S. EL MOLINO AVE.TELEPHONE:
(626) 578-0460
CITY:PASADENASTATE: CAZIP CODE:
91101
CAPACITY:206CENSUS: 97DATE:
11/23/2020
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Virginia Garcia, AdministratorTIME COMPLETED:
02:15 PM
NARRATIVE
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An informal virtual meeting was held with administrator, Virginia Garcia, assistant administrator, Lori Lackey and Wellness Director, Rocio Gonzalez. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s meeting was conducted telephonically. Present for the meeting were Regional Manager (RM) Araceli Ramirez, Licensing Program Manager (LPM) Adeline Ho and Licensing Program Analyst (LPA) Tony Vasallo. The purpose of the meeting is to discuss the ongoing compliance issues at the facility regarding Personal Protective Equipment (PPE) use and COVID-19 policies and procedures.

Pasadena Public Health (PPH) has physically visited the facility several times during the COVID-19 pandemic and has noted that staff are using PPE's improperly. Our department has also conducted virtual tours and have observed staff using PPE's improperly. Also during the virtual tour the administrator has mentioned staff have been written up or suspended for not using the PPE's properly. Administrator indicated staff have been trained regarding PPE's approximately 7 times since the beginning of the pandemic. Also discussed were the documents submitted to PPH regarding admission policies and in-service training. The facility has submitted the documents to PPH several times for approval and they have not been approved due to being incomplete or in the wrong format.

Administrator was notified that deficiencies will be issued due to the constant issues regarding PPE's and incomplete documents submitted to PPH. The deficiencies are documented on the attached 809D.

A telephonic exit interview was conducted with Virginia Garcia, and a hard copy was provided via email for signature along with appeal rights.

SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2020
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: JASMIN TERRACE AT EL MOLINO
FACILITY NUMBER: 197607655
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/23/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/24/2020
Section Cited

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Additional Personal Rights of Residents in Privately Operated Facilities (a) Personal Rights....
(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
Type A
11/24/2020
Section Cited

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Administrator - Qualifications and Duties
(h) The administrator shall have the responsibility to:
(8) the personal characteristics, physical energy and competence to provide care and supervision and, where applicable, to work effectively with social agencies.

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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: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2020
LIC809 (FAS) - (06/04)
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