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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607655
Report Date: 11/29/2022
Date Signed: 11/29/2022 03:07:48 PM


Document Has Been Signed on 11/29/2022 03:07 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: 120DATE:
11/29/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Lori Lackey - Assistant Administrator TIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst(s) Mary Flores conducted a case management visit to follow up on an incident report send to the department on 11/4/22. LPA Flores met with Lori Lackey Assistant Administrator and explained the reason for the reason.

On 11/4/22 LPA Flores reviewed incident report regarding Resident #1(R1). Incident report notes that on 10/31/22 R1 was not found in her room at around 7:30pm. Caregiver made facility administration aware and upon checking facility's cameras it was discovered R1 had left the facility around 6:00pm when a delivery driver opened the door. Last caregiver check on 10/31/22 was conducted at 5:26pm and R1 was seen then. Facility contacted Pasadena Police Department(PPD) and (2) two staff went out looking for R1. During the course of the report intake with PPD they were notify that R1 was found. Pasadena Police department officer returned with R1 at 9:52pm.

On 11/29/22 LPA Flores conducted a file review of R1's personal file at the facility. The following was observed: Physician's Report dated 7/6/22 notes R1's primary diagnosis is Dementia and notes R1 has wandering behavior and is not able to leave the facility unassisted. Face Sheet notes R1's date of admission was 2/15/21. R1 is under conservatorship, appointed person is to make person and estate decisions for R1. During the visit LPA was notified that a second incident happened on 11/27/22 a copy of the internal incident report was provided to LPA which notes R1 left the facility unassisted on 11/27/22 at 11:30am after a family entered the facility, staff noticed she was no longer in the lobby's sofa and went to look for R1. R1 returned to the facility at 1:20pm. On 11/29/22 LPA Flores was allowed entry to the facility through the main door after ringing the bell, door did not lock behind LPA. LPA observed one receptionist was on a phone call and there were around 7 residents in the lobby, LPA followed to check the door to see if it locked, door continue to be unlocked and after LPA's attempt, receptionist followed to lock the door. Per Assistant administrator staff have to flip switch for door to lock after an entry to lock the door.
(CONTINUED ON LIC 809C)
SUPERVISOR'S NAME: Stefanie CoronelTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
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 3


Document Has Been Signed on 11/29/2022 03:07 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: 11/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/30/2022
Section Cited

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: (a) ... Section 87468.1, Personal Rights of Residents...(4) To care, supervision,... meet their individual needs...by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement is not met as evidence by:
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Based on documents review facility did not ensure R1 did not leave the facility unattended which is an immediate risk to the health, safety, or personal rights to the persons in care.
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Type B
12/06/2022
Section Cited

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87411 Personnel Requirements - (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...
This requirement is not met as evidence by:
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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: 11/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/29/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


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: 11/29/2022
NARRATIVE
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LPA reviewed facility's video on 11/27/22 at 11:19:03am two visitors enter the facility the door closes behind them and at 11:19:26am R1 opens the door and exits the building.

Deficiencies are noted on LIC 809D per Title 22 Regulations.

Exit interview was conducted with Lori Lackey Assistant Administrator and a copy of this report, LIC 809D, 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: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC809 (FAS) - (06/04)
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