<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607655
Report Date: 11/17/2021
Date Signed: 11/17/2021 03:47:32 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:
11/17/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
03:26 PM
MET WITH:Lori Lackey - Assistant Administrator TIME COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
icensing Program Analyst(s) Mary Flores conducted a case management COVID 19 visit regarding facility following all CDC, department of public health and department recommendations. LPAs met with Lori Lackey Assistant Administrator and explained the reason fro the visit.

LPA toured the first floor with Rocio Gonzalez wellness director and observed the following:
Screening logs were observed and desk front staff took visitors temperature. The following screening logs were observed; outside agencies, family sign, and staff with the following questions: Name, Temp, Fever/chills, coughing, shortness of breath/difficulty breathing, fatigue, muscle or body ache, headache, new loss of taste or smell, sore throat, congestion/runny nose, nausea/vomiting, diarrhea, outside the U.S. in the last 14 days within the last 48 hours.
LPA observed staff present in the dinning room, activity room, and patio and one resident was observed sitting at each table.
Signs are posted throughout the facility in English and Spanish side by side.
Break room was observed with only two chairs. Clock in machine was observed been disinfected before and after use.

No deficiencies were observed during this visit.

Exit interview was conducted with Rocio Gonzalez wellness director 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: 11/17/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2021
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 1