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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607655
Report Date: 01/25/2023
Date Signed: 01/25/2023 02:56:49 PM


Document Has Been Signed on 01/25/2023 02:56 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
GREATER LA AC/SC, 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: 127DATE:
01/25/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Virginia Garcia - Administrator TIME COMPLETED:
03:00 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 and Licensing Program Manager (LPM) Tony Vasallo conducted an Informal Office meeting at the regional office with Virginia Garcia Administrator.

During the meeting the following was discussed:
  • The purpose of the meeting was explained to the administrator Virginia Garcia.
  • LPA Flores provided findings for complaint #28-AS-20210303163807. Findings regarding allegation resident #1(R1) sustained a fracture while in care were substantiated as there was enough evidence during interviews conducted and records reviewed.
  • Additional staffing to ensure sufficient staffing for each shift. When hiring staff through registry facility is to ensure staff is properly trained to perform duties. Facility provides training to staff in English/Spanish.
  • Additional deficiency is noted during this visit related to complaint investigation where it was revealed that staff #2(S2) was discovered using Resident #1's (R1) private bathroom. On 2/23/21 R1's responsible party visited R1 upon walking into the room found R1 sitting in a chair and S2 exiting R1's bathroom pulling him/her pants up. S2 confirmed he/she used R1's bathroom and it was not unusual for staff to use the resident's bathrooms. S2 had been provided two disciplinary notices prior to the incident. Disciplinary notice dated: 2/21/20 notes S2 used another resident's bathroom to shower another resident. Disciplinary notice dated: 7/13/20 notes S2 yelled at another staff who was attempting to assist S2 with resident care. S2 reassigned to the position as a caregiver after the incident.
  • Plan of correction for deficiencies were discussed with Administrator.

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

Exit interview was conducted with Virginia Garcia Administrator and a copy of this report, LIC 809D, and appeal rights were provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
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 2


Document Has Been Signed on 01/25/2023 02:56 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
GREATER LA AC/SC, 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: 01/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/21/2023
Section Cited

1
2
3
4
5
6
7
Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.

This requirement is not met as evidence by:
1
2
3
4
5
6
7
Administrator will provide a plan with topics and identify consultant agency to provide proper personal rights training by 1/26/23 and will submit training agenda and sign-in by 2/8/23.
8
9
10
11
12
13
14
Based on documents review licensee did not ensure S2 follow residents rights by using R1's private bathroom which poses a potential health, safety, or personal rights risk to the persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 01/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2