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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607655
Report Date: 02/27/2023
Date Signed: 02/27/2023 11:22:13 AM


Document Has Been Signed on 02/27/2023 11:22 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
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: 135DATE:
02/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:38 AM
MET WITH:Rocio Gonzalez - Wellness Director TIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced annual visit at the facility with focus on infection control domain, medication, and food review. LPA Flores met with Rocio Gonzalez Wellness Director and explained the reason for the visit.

The facility is licensed to serve 206 residents over the age of 60 years old of which 171 may be non-ambulatory, 35 bedridden, and a hospice waiver for 20 hospice residents. There are currently 12 residents on hospice. Facility cares for dementia residents and has delayed egress on exit doors. There is a water feature in the courtyard. The water feature has a fence around the entire perimeter. Facility has a fire sprinkler system throughout the facility.

LPA Flores conducted a tour of the facility with Rocio Gonzalez Wellness Director and observed the following:
Upon arriving at the facility, receptionist conducted screening of LPA and observed signing logs with COVID related questionnaires. Signs are posted throughout the common areas, social distance was observed among the residents. Staff were observed wearing face masks.
Facility has a commercial kitchen. Kitchen is clean and food supplies were observed to be sufficient food for at least 2 days of perishables and 7 days of non-perishables. Facility has obtained a temporary walking freezer that is maintain outside the kitchen while repairing the indoor walking freezer. LPA observed the following rooms # 123,130, 223, 235, and 239. Each room has sufficient lighting, proper furniture, and bedding supplies. Each room has a private bathroom in working condition with grab bars, and skid strips/mats and water temperature was tested between 100.0 - 110.6 degrees F. which is not within the required 105-120 degrees F.
LPA Flores checked medication for 5 residents. Administrator Certificate #6020807740 exp: 1014/24 was observed for Virginia Garcia and a copy of Liability Insurance was required.

Deficiencies have been noted on LIC 809D and a copy of this report, LIC 809D, and appeal rights have been provided during exit interview with Lori Lackey Assistant Administrator.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2023
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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Document Has Been Signed on 02/27/2023 11:22 AM - 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: 02/27/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in bathroom in room #130 water temperature tested at 100.0 degrees F., and bathroom in room #239 water temperature tested at 101.6 degrees F., which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/06/2023
Plan of Correction
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Administrator will adjust water heater and ensure temperature is at the required temperature of 105-120 degrees F. at all times. Administrator will submit a water temperature log from 2/28/23 - 3/6/23 for room #130 and 239 water should be tested at least twice a day to the department by POC due date 3/6/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Tony VasalloTELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2023
LIC809 (FAS) - (06/04)
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