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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607655
Report Date: 03/11/2022
Date Signed: 03/11/2022 04:02:27 PM


Document Has Been Signed on 03/11/2022 04:02 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: DATE:
03/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:TIME COMPLETED:
04:15 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 and Deputy Director Kevin Gains conducted an unannounced annual visit at the facility with focus on the infection control domain, food and medication review. LPA and Deputy Director met with Malou Bernardo Business Office Manager and explained the reason for the visit. Rocio Gonzalez Wellness Coordinator arrived 20 minutes later.

The facility is licensed to serve 206 residents over the age of 60 years old of which 171 may be non-ambulatory, 35 bedridden, and a hospice waiver for 20 hospice residents. There are currently 12 residents on hospice. Facility cares for dementia residents and has delayed egress on exit doors. There is a water feature in the courtyard. The water feature has a fence around the entire perimeter. Facility has a fire sprinkler system throughout the facility.

LPA, Deputy Director and Malou Bernardo Business Office Manager conducted a tour of the facility and observed the following:

All common areas are clean and in good repair. Kitchen was observed clean, food was reviewed and sufficient for at least 2 days of perishables and 7 days of non-perishables. Freezer's temperature was observed at 10 degrees F. which is not within the required temperature of 0 degrees F. Resident's bedrooms #110,116,119, 138,245,248,252,255,259,263 were observed, all bedrooms have sufficient lighting, furniture, and bedding; room #110 - has a broken bed frame. Bathrooms were observed in each room and each has the required grab bars, bathroom #3 next to vent water damage was observed of about the size of a pen. bathroom #3, 7, 9 were missing a skid mat in the shower. Water temperature was tested in each resident's bathroom and tested between 99.1 - 109.5 degrees F. which is not within the required 105-120 degrees F. Medication and files were reviewed for resident #1,2,3,4,5,6,7,8,9,10,11, for resident #2,4,6,7,9,10 medication sheet was missing staff's initials next to dose provided for March 10th and 11th. files for staff #1,2,3,4,5,6 were reviewed.
(CONTINUED ON LIC 809D)
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022
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 6


Document Has Been Signed on 03/11/2022 04:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 MOLINO
FACILITY NUMBER: 197607655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(21)
General Food Service Requirements
(b) The following food service requirements shall apply: (21) Freezers of adequate size shall be maintained at a temperature of 0 degree F (-17.7 degree C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degree F. (4 degree C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2022
Plan of Correction
1
2
3
4
Facility will ensure freezer's temperature is under 0 degrees at all times by certifying in LIC 9098 by 3/12/22 and will submit a temperature log and a professional service invoice for freezer by 3/18/22.
Type A
Section Cited
CCR
87465(d)(3)
87465 Incidental Medical and Dental Care: (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication and is unable to communicate his/her symptoms... (3) The date and time... medication was taken, the dosage taken, and the residen'ts response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in 6 out of 11 residents did not have staff's initials in medication sheet which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/12/2022
Plan of Correction
1
2
3
4
Licensee will ensure that staff are provided in-service training and submit a signing log and agenda of training to the department by 3/12/22.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022
LIC809 (FAS) - (06/04)
Page: 2 of 6


Document Has Been Signed on 03/11/2022 04:02 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 MOLINO
FACILITY NUMBER: 197607655

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 5 out of 11 resident's bathroom were water temperature was tested was at: room #138 tested 104.7 degrees F., #248 tested at 103.7 degrees F., #252 tested 102 degrees F., #259 tested at 99.1 degrees F., and #263 tested at 103.2 degrees F., which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2022
Plan of Correction
1
2
3
4
Administrator will adjust water temperature to the required water temperature and will maintain a log for the next 7 days to be submitted to the department by 3/18/22.
Type B
Section Cited
CCR
87303(e)(5)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (5) Non-skid mats or strips shall be used in all bathtubs and showers.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above in 3 out 11 resident's bathroom observed did not have a skid mat in the shower which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/18/2022
Plan of Correction
1
2
3
4
Administrator will ensure each resident is provided a skid mat will provide a picture of skid mat in each bathroom and in service training to staff sigining log and agenda to the department by 3/18/22.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 03/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/11/2022
LIC809 (FAS) - (06/04)
Page: 3 of 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 MOLINO
FACILITY NUMBER: 197607655
VISIT DATE: 03/11/2022
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
26
27
28
29
30
31
32
Facility is following infection control recommendations and guidelines, except for screening residents upon returning from outings.

Deficiencies will be noted on LIC 809D per Title 22 Regulations Chapter 6 Division 8.

Exit interview was conducted with Lori Lackey Assistant Administrator and a copy of this report, LIC 809D, Technical Advisory, and Appeal Rights were provided.
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
LIC809 (FAS) - (06/04)
Page: 6 of 6