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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607655
Report Date: 03/03/2022
Date Signed: 03/03/2022 03:35:32 PM


Document Has Been Signed on 03/03/2022 03:35 PM - It Cannot Be Edited

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:
03/03/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
02:34 PM
MET WITH:Rocio Gonzalez - Wellness CoordinatorTIME COMPLETED:
03:30 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
Licensing Program Analyst(s) (LPA) Mary Flores conducted an unannounced case management visit regarding COVID 19 recommendations and guidelines. LPA Flores met with Rocio Gonzalez Wellness Coordinator and explained the reason for the visit.

LPA Flores conducted a tour of the facility with Rocio Gonzalez Wellness Coordinator and observed the following:

Facility is currently following COVID 19 (infection control) recommendations.
Staff were observed wearing face mask and googles.
Residents were observed maintaining social distancing.
Facility has signs throughout the facility in Spanish and English.
PPE supplies were observed for at least 30 days.
Facility has a yellow and red zone designated areas to assist with isolation and quarantine when necessary.
Sufficient food was observed.

No deficiencies were given during this visit.

Exit interview was conducted with Malou Bernado Business Manager 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: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2022
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