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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607655
Report Date: 11/12/2021
Date Signed: 11/12/2021 03:12:16 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: 113DATE:
11/12/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Virginia Garcia - Administrator TIME COMPLETED:
03:30 PM
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Licensing Program Analyst(s) Mary Flores and Jewel Baptiste conducted a case management COVID 19 visit regarding facility following all CDC, department of public health and department recommendations. LPAs met with Virginia Garcia administrator.

LPAs toured the facility 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 floating 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.
Disinfectant spray has been updated to a 1 minute contact to wipe, 2 housekeepers were asked regarding disinfecting and process. Logs were noticed throughout the facility with disinfecting times at least 3 times a day, which are being done once per shift, or as needed.
2 Med Techs, 1 kitchen staff were observed holding a small bottle of hand sanitizer in their pockets.
Emergency exits were cleared.
LPAs observed 1 kitchen staff verbalized and model hand washing procedure and 1 caregiver model donning and doffing. LPAs observed ice machine cleaning log on ice machine lid.
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 Virginia Garcia administrator 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: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
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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