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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607655
Report Date: 04/06/2022
Date Signed: 04/06/2022 02:32:24 PM


Document Has Been Signed on 04/06/2022 02:32 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 - IncidentUNANNOUNCEDTIME BEGAN:
01:01 PM
MET WITH:Lori Lackey Assistant Administrator TIME COMPLETED:
02:45 PM
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Licensing Program Analyst(s) (LPA) Mary Flores conducted a case management visit to follow up on incident report and adult abuse report (SOC 341) faxed to the department on 4/6/22. LPA met with Lori Lackey assistant administrator and explained the reason for the visit.

LPA Flores reviewed staff's file and requested a copy of staff roster, incident report, SOC 341, staff #1(S1) and #2(S2)'s training, personnel record, criminal background clearance,termination letter for S1 and resident #1(R1)'s identification and emergency information sheet, admission agreement, individual service plan, physician's report and resident appraisal. LPA Flores interview staff #2.

Incident report dated 4/6/22 reports that on 4/3/22 S2 requested assistance with R1 over the radio and S1 was responded to the call. R1 "suddenly struck S1 in the face and S1 hit her back in the face. S1 stated first instinct was to hit back. R1 was observed for injuries and no injuries were observed. After internal investigation facility concluded to terminate S1. S1 Document's review for R1 show no history of aggressive behaviors recorded, R1 is non-ambulatory. Individual Service Plan does not have any notes regarding providing assistance for behaviors.

Further investigation is required. No deficiencies were given during this visit.

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: 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)
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