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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607655
Report Date: 03/28/2022
Date Signed: 03/28/2022 10:41:53 AM


Document Has Been Signed on 03/28/2022 10:41 AM - 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: 110DATE:
03/28/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lori Lackey - Assistant Administrator TIME COMPLETED:
11:00 AM
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Licensing Program Analyst(s) (LPA) Mary Flores conducted a plan of correction (POC) visit to follow up on deficiencies given on 3/11/22. LPA Flores met with Lori Lackey Assistant Administrator and explained the reason of the visit.

The following deficiencies were observed during the annual visit on 3/11/22:
Section 87555(b)(21) General Service Food Requirements - On 3/11/22 Freezer's temperature was observed at 10 degrees which is not within the required temperature of 0 degrees. On 3/28/22 LPA Flores observed freezer thermometer at 0 degrees, on 3/18/22 LPA Flores received invoice for services provided by Heating and Air Conditioning contractor provided on 3/14/22. Deficiency is cleared.

Section 87465(d)(3) Incidental Medical and Dental Care - On 3/11/22 during medication review medication was reviewed and medication sheets were not initial upon providing medication to residents. On 3/28/22 LPA Flores reviewed medication and medication sheets for resident #1,#2,#3,#4. Deficiency has been cleared.

Exit interview was conducted with Lori Lackey assistant 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: 03/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2022
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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