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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607655
Report Date: 04/06/2022
Date Signed: 04/06/2022 02:31:46 PM


Document Has Been Signed on 04/06/2022 02:31 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: 105DATE:
04/06/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
12:57 PM
MET WITH:Lori Lackey Assistant Administrator TIME COMPLETED:
01:45 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 -COVID 19 to follow up on recommendations. LPA Flores met with Lori Lackey assistant administrator and explained the reason for the visit.

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

Screening logs are located in the front desk and have record of signing in for staff, family, and other agencies for the past week, including temperature record, and questionnaire.
Staff were observed wearing face masks throughout the facility.
Staff were inquired about hand sanitizer accessible in their pockets.
Residents were observed six feet apart and encourage to wear a face mask during cards activity.
Red Zone available in the first floor, and quarantine area in the second floor, closed lid trash cans observed, PPE supplies observed outside the quarantine/yellow zone area.
Staff reminded visitor to keep face mask on during the visit.

No deficiencies given 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: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2022
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