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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607655
Report Date: 10/19/2021
Date Signed: 10/19/2021 03:51:54 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:
10/19/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:49 PM
MET WITH:Virginia Garcia - Administrator TIME COMPLETED:
04:15 PM
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Licensing Program Analyst(s) Mary Flores and Jewel Baptiste conducted a plan of correction visit (POC) for deficiencies given on 10/11/21. LPAs met with Virginia Garcia Administrator and explained the reason for the visit.

On 10/11/21 LPAs gave the following deficiencies:
87303(i)(1)(B) - Maintenance and Operation - Facility staff did not responded to emergency call respond in rooms #134, 239, 217. During today's visit LPA Baptiste tested the emergency call service in rooms #134, 239, 217 and a caregiver responded within 3 minutes. Deficiency has been cleared on 10/19/21.

LPAs observed the following Infection control corrections:
Visitors Log had additional questions per CDC guidelines.
Signs are posted in English and Spanish throughout the facility.
Disinfecting wipes were placed next to staff sign-in machine.
Closed lid trash cans were observed in the common restrooms.
Staff were present in the common areas.

Exit interview was conducted with Virginia Garcia - Administrator a copy of the report was provided.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
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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