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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607655
Report Date: 06/29/2021
Date Signed: 06/29/2021 03:18:58 PM

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: 112DATE:
06/29/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:07 PM
MET WITH:Lori Lackey - Assistant Administrator TIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Mary Flores conducted a case management visit due to deficiencies related to required reporting requirements that must be reported to Pasadena Department of Public Health (PDPH).

On 6/17/21 LPA Flores was contacted by PDPH representative and notified LPA regarding facility not providing required documents upon admission of new residents to PDPH. On 4/22/21 Facility's administrator Virginia Garcia, assistant administrator Lori Lackey, Community Care Licensing Division (CCLD) Regional Manager Araceli Ramirez, Licensing Program Manager (LPM) Rebecca Orendain, LPA Flores, and PDPH Facility's assigned nurse Whitney Frame held an office meeting in which it was discuss facility will ensure to submit 2 out of 3 documents within 24 hours upon admission of new residents to the facility; ALW Verification of Approval, Vaccination Card, and/or Declination of Vaccination which could be submitted before admission, the day of, or 24 hours after admission.

On 6/29/21 LPA Flores reviewed email from PDPH nurse and facility has failed to submit one or more documents within 24 hours of admission for resident #1(R1), #2(R2), #3(R3), #4(R4), #5(R5), #6(R6), #7(R7) as required by PDPH under COVID 19 recommendations and guidelines.

Per Title 22, Division 6, Chapter 8, Section 87211 Reporting Requirements;21 facility is to report to the department in this case PDPH of any occurrences within 24 hours. Therefore, deficiencies will be cited in the attached LIC 809D.

Exit interview was conducted Lori Lackey Assistant administrator with and a copy of this report was provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 06/29/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/29/2021
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, 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: 06/29/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/13/2021
Section Cited

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87211 Reporting Requirements: (a) Each licensee shall furnish...such reports as the Department may require,...: (2) Occurrences,... which threaten the welfare, safety or health of residents, ... within 24 hours either ... to the licensing agency and to the local health officer... This requirement is not met as evidence by:
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Based on documents reviewed Administrator failed to submit required documentation for 7 new admissions to the facility based on PDPH evaluation which poses a potential Health, Safety, or Personal Rights risk to persons 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: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 06/29/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2021
LIC809 (FAS) - (06/04)
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