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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607655
Report Date: 10/04/2021
Date Signed: 10/04/2021 02:58:16 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: 121DATE:
10/04/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Lori Lackey - Assistant Administrator TIME COMPLETED:
03:15 PM
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Licensing Program Analyst(s) (LPA) Mary Flores, Program Regional Manager (RM) Araceli Ramirez, and Pasadena Department of Public Health Nurse(s) (PDPH -HFEN) Sharon Evangelista and Whitney Frame conducted an unannounced case management COVID 19 visit. LPA, RM, and PDPH-HFEN met with Lori Lackey assistant administrator and explained the reason of the visit.

LPA, RM, PDPH-HFENs assistant administrator, and wellness coordinator conducted a tour of the facility and observed the following:
Facility has one entry point, and screening was conducted upon entering the facility. Screening questionnaire needs to be updated to show current symptoms.
COVID 19 Signage must be updated to show current symptoms in languages applicable for current population of residents/staff and must be posted throughout the facility. Hand washing sign must be updated and posted in all common sinks where hand washing is conducted with the proper steps.
Social distancing must be observed in the dinning areas and alternative options may be put in place to ensure 6 feet distance is kept within residents.
Staff were observed wearing a face covering and facility is to ensure staff wear the proper face mask of a surgical mask, N95 when necessary and staff are aware of proper usage.
PPE supplies were observed, facility has 60 days of gowns and gloves. Facility needs to ensure all PPE supplies including but not limited to surgical mask, N95s, face shields, gowns, gloves, hand sanitizer, and disinfectant spray are provided.
Logs for disinfecting were observed. Facility will ensure staff maintain log current after disinfecting surface areas.
Residents were observed without face masks. Facility will provided updates to residents and will encourage residents to wear a surgical mask when residents are in the common areas.
Closed lid trash cans were observed, trash can in dinning room next to sink was not working and trash cans in yellow zone were not label. Facility will ensure trash cans are working and label in the yellow area.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021
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
VISIT DATE: 10/04/2021
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Break room was observed, no disinfecting was observed. It was recommended to provide disinfecting wipes to clean down surfaces used after each use.

RM Ramirez, LPA and PDPH-HFENs discussed the items above and recommended in service training to be provided to all staff regarding the items discuss.

Technical advisories were given during this visit under COVID 19 recommendations.

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

DATE: 10/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2021
LIC809 (FAS) - (06/04)
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