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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607655
Report Date: 10/11/2021
Date Signed: 10/11/2021 04:36:27 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:
10/11/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:38 AM
MET WITH:Rocio Gonzalez -Wellness Director and
Virgnia Garcia - Administrator 		TIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Mary Flores and Jewel Baptiste conducted an unannounced annual visit using the inspection tool. LPAs met with Rocio Gonzalez Wellness Director and explain the reason for the visit. Pasadena Department of Public Health Nurses Whitney Frame and Kevin Grellman join LPAs at 10:30am.

The facility is licensed to serve 206 residents over the age of 60 years old of which 171 may be non-ambulatory, 35 bedridden, and a hospice waiver for 20 hospice residents. There are currently 12 residents on hospice. Facility cares for dementia residents and has delayed egress on exit doors. There is a water feature in the courtyard. The water feature has a fence around the entire perimeter. LPAs conducted a tour of the facility with Rocio Gonzalez and observed the following regarding Physical Plant and Food Service Domain:
Resident rooms were randomly chosen #209, 214, 217, 220, 223, 232, 239, 256, 122, 125, 130, 134, 136, LPAs observed all required furniture, bedding items, sufficient lighting, in each bedroom and resident's bathrooms were observed with skid mats/skid strips, grab bars, and water was tested between 98.5 and 114.5 degrees F which is not within the required range of 105 - 120 degrees F. The large commercial kitchen was toured, sufficient food was observed, refrigerators' temperature was observed at 40 degrees and freezer's temperature was observed at 0 degrees. LPAs tested emergency call light in room #217, 239, 134 caregivers did not responded to call, LPAs and wellness director waited for 5 minutes.

Infection Control Domain: LPAs observed updated COVID signs around the facility, screening questionnaire was updated, in service training were provided to staff regarding proper hand washing, face covering, social distancing, proper disinfecting, donning and doffing. Staff had individual hand sanitizers. It was recommended that all disinfected bottles are label and dated, and that additional closed lid trash cans are provided in the restrooms. As well as further in service training for staff regarding COVID 19 recommendations and guidelines.

Deficiencies were given during this visit under Title 22. Exit interview was conducted with Virginia Garcia administrator and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 7
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: 10/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 2 out of 13 rooms observed nail polish under the sink in room #223 and all purpose cleaner in room #122 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/12/2021
Plan of Correction
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Wellness Coordinator removed the items during the visit. Deficiency cleared during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 10/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2021
LIC809 (FAS) - (06/04)
Page: 2 of 7
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: 10/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as LPAs observed water temperature as follow in rooms #256 tested at 103.0; #122 tested at 102.3; #130 tested 102.4; #134 tested at 98.5; #136 tested at 102.1; and water temperature in sink area in dinning room tested at 100.4 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2021
Plan of Correction
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Administrator will ensure water temperature is maintain at the required temperature of 105 - 120 degrees F at all times will certify with LIC 9098 and submit a temperature log for each room for the next seven days by 10/18/21.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 10/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2021
LIC809 (FAS) - (06/04)
Page: 3 of 7
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: 10/11/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(i)(1)(B)

Facilities shall have signal systems which shall meet the following criteria: (1) All Facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall (B) transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in LPAs tested call signal in rooms #134, 239, and 217 and staff did not respond as staff at front desk were not able to visually see light was on to let staff know to assist resident which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/12/2021
Plan of Correction
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Administrator is to ensure staff at the reception area have a visual or in addition an auditory signal to signal call to be able to respond to residents in a proper amount of time by 10/12/21.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 10/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/11/2021
LIC809 (FAS) - (06/04)
Page: 7 of 7