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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607655
Report Date: 01/19/2022
Date Signed: 01/20/2022 04:24:54 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: 108DATE:
01/19/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Rocio Gonzalez - Wellness Director
Virginia Garcia - Administrator
TIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Mary Flores, Pasadena Department of Public Health Nurse Consultant (HFEN) Sharon Evangelista, and HFEN -Jonah Nugraha conducted an unannounced case management visit regarding COVID 19 guidelines. LPA and HFENs emt with Rocio Gonzalez and explained the reason of the visit. Virginia Garcia administrator arrived 20 minutes later.

LPA Flores and HFENs conducted a tour of the facility with Rocio Gonzalez and observed the following;

Screening books, COVID questionnaire, and temperature check were in place upon arrival.
Staff were observed wearing N95 mask and googles or face shields. HFEN Evangelista advise surgical mask may be wear in the green zone.
Staff was observed disinfecting high touch areas and logs are maintain.
Kitchen was observed staff showed HFENs cleaning and disinfecting supplies.
Residents with booster vaccine and negative test results were observed performing activity's.
Facility has set up red zone at the end of hall in rooms # 138 and 137. PPE supplies are set up outside the exit door with entrance through the patio, additional trash cans were placed next to PPE supplies.
LPA reviewed administrator Virginia Garcia' s email to LPA, Licensing program manager, regional manager, Pasadena department of Public Health LTCF support and local ombudsman received on 1/12/22 notifying of positive cases along with line list.

No deficiencies were given during this visit.

Exit interview was conducted with Virginia Garcia administrator and a copy of this report was email for signature.

*This is an electronic copy of written report provided on 1/19/22 during the visit and supersedes written report.*
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2022
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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