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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607655
Report Date: 02/09/2022
Date Signed: 02/09/2022 02:16:56 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: 107DATE:
02/09/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Virginia Garcia - Administrator TIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced case management COVID 19 visit to follow with COVID 19 recommendations. LPA Flores met with Virginia Garcia administrator and explained the reason for the visit.

LPA Flores and Virginia Garcia administrator conducted a tour of the facility at around 1:20pm:
  • Screening list were observed for visitors, other agencies, and staff in the front desk. Receptionist was observed taking temperature of a visitor.
  • Social distance was observed among the residents. Some residents were observed wearing surgical mask.
  • Staff was observed wearing surgical or N95 mask and googles.
  • Random staff was asked to reach for hand sanitizer in pocket.
  • Kitchen staff were observed wearing mask while performing their duties, and preparing meals. Sufficient food was observed. Three (3) sanitizer prepared buckets were observed throughout the kitchen.
  • Signs were observed in the front lobby, throughout the facility, and near hand washing sinks.
  • Break room was observed with set up for 2 staff per use, signs, and sanitizing wipes available.
  • Medication staff, showed LPA hand sanitizer, and sanitizing spray, and explained to be disinfecting after providing medication to each resident.
  • Housekeeper showed LPA labeled disinfecting spray. Facility is cleaning and disinfecting every shift.
  • A wing in the first floor has been designated as the red zone with an entrance through the patio, there are PPE supplies set up in the patio entrance, and three covered trash cans.

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: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022
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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