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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607655
Report Date: 01/05/2022
Date Signed: 01/19/2022 04:12:14 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: DATE:
01/05/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
02:01 PM
MET WITH:Virginia Garcia - AdministratorTIME COMPLETED:
03:20 PM
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Licensing Program Analyst(s) (LPA) Mary Flores conducted a case management visit to follow up on facilities COVID 19 recommendations and guidelines. LPA Flores met with Virginia Garcia and explained the reason for the visit.

LPA Flores conducted a tour with Virginia Garcia administrator and observed the following:
One entry point with screening logs for visitors with all screening questions.
Signs posted in the lobby, bathrooms, and throughout the facility.
Social distancing was observed in dining room, activity room.
Staff were observed in dining/activity room, and throughout the facility wearing surgical mask and googles or face shield. Four random staff were asked to show personal hand sanitizer kept in their pocket.
Cleaning logs were observed up to date with 3 - 6 entries per day throughout the facility.
Facility is being clean and disinfect at least each shift, facility has 3 shifts.
Some residents were observed wearing face mask in activity/dining room.
Break room, medication room, and clock in area were observed to have disinfecting wipes available.
LPA Flores observed two caregivers conduct donning and doffing of full PPE supplies and conduct proper hand washing.
Administrator inquire regarding visitation guidelines. LPA advice administrator to follow visitation guidelines per PIN 21.40ASC.

Facility is currently following all COVID 19 recommendations. No deficiencies were given 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: 01/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022
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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