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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607655
Report Date: 10/27/2021
Date Signed: 10/27/2021 03:04:00 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: 141DATE:
10/27/2021
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
02:38 PM
MET WITH:Virginia Garcia - AdministratorTIME COMPLETED:
03:20 PM
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Licensing Program Analyst(s)(LPA) Mary Flores and Jewel Baptiste conducted a plan of correction visit for deficiency given on 10/19/21.

On 10/19/21 LPAs gave a deficiency:

87465(e) Incidental Medical and Dental - LPAs observed PRN medication provided to residents without labels. During today's visit LPAs observed labels on PRN medication. Deficiency has been cleared.

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

DATE: 10/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2021
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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