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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 10:41:12 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:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Lori Lackey - Asssistant Administrator TIME COMPLETED:
10:00 AM
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Licensing Program Analyst(s) Mary Flores conducted a case management visit COVID 19 to follow up with guidance and recommendations regarding infection control. LPA Flores met with Lori Lackey Assistant Administrator and explained the reason of the visit.

LPA Flores conducted a tour with Lori Lackey assistant administrator and observed the following:

Screening upon arrival for visitors, front lobby staff screens for temperature visitor's log, family log, and staff log available. Screening logs were reviewed for staff signing in for 3/28/22.
Quarantine/Isolation areas were observed PPE supplies were observed in cabinet outside the room.
Social distancing in dining room and activity areas, residents observed having breakfast and having exercises with proper distance from each other.
Staff were observed wearing a face mask and face shield at all times.
Cleaning logs are posted.
Posters in quarantine area are posted.

No deficiencies cited during this visit.

Exit interview 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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