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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 11:22:57 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:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
10:48 AM
MET WITH:Lori Lackey - Assistant Administrator TIME COMPLETED:
11:30 AM
NARRATIVE
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LPA Flores conducted an unannounced case management visit regarding COVID 19 guidelines notify to the department via email during an annual visit on 2/27/23. LPA Flores met with Lori Lackey Assistant administrator and explained the reason for the visit.

On 2/6/23 LPA Flores was copy on an email and received a picture of Staff/Administration #1 - Conrad Garcia in the dining room on a phone call without a face mask. On 2/25/23 LPA Flores was copy on an email notifying staff #2 - Rocio Gonzalez Wellness Director was observed without a face mask at the facility. During an unannounced annual visit conducted on 2/27/23 LPA Flores interview staff#2 who recognize she had arrived at the facility without a mask and there were no face mask available in the front desk, leading staff to walk to her office to get a face mask. Per receptionist face mask had to be replenish the morning of 2/25/23.

Deficiencies have been noted on LIC 809D.

Exit interview was conducted with Lori Lackey Assistant Administrator and a copy of this report was provided.
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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/06/2023
Section Cited

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(c) An Infection Control Plan...shall be included in the Plan of Operation required by Section 87208.(1)... shall includ e...:(F) Staff shall demonstrate knowledge of and skill in infection control, as appropriate to the job assigned and as evidenced by safe and effective job performance.
This requirement is not met as evidence by:
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Administrator will ensure all staff are knowledge of all current guidelines regarding face mask around the facility and will ensure supplies are available at the front desk at all times. Certification in writting will be submitted to the department by POC due date 3/6/23.
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Based on interviews conducted Licensee did not ensure staff are following COVID 19 guidelines and supplies are replenish over night which poses a potential risk to the health, safety, or personal rights of the persons in care.
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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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