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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607655
Report Date: 07/06/2023
Date Signed: 07/06/2023 03:29:42 PM


Document Has Been Signed on 07/06/2023 03:29 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: DATE:
07/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:31 PM
MET WITH:Virginia Garcia - Administrator TIME COMPLETED:
03:45 PM
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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced case management visit to follow up on incident report submitted to the department on 6/30/23. LPA met with Virginia Garcia administrator and explained the reason for the visit.

On 6/30/23 facility submitted incident report regarding resident #1(R1). On 6/26/23 R1 sustained a fall during an episode of seizure while taking a shower. At the time of the incident R1 was evaluated by supervisor. After the seizure R1 was in sleep state and unable to communicate symptoms. Per wellness director, hospice was contacted. A nurse arrived to evaluate R1 within 30 minutes of incident, and verbally provided recommendations for R1. On the morning of 6/27/23 caregiver went to assist R1 and noticed R1 was moaning. Facility contacted hospice and responsible party at that time. On 6/27/23 hospice requested a x-ray. On 6/28/23 x-ray was conducted and revealed R1 sustained a subcapital fracture of the femoral neck to the right hip. Per documents reviewed, R1 was admitted to hospice after "an episode of seizure" on 2/2/23. Last physician report was conducted by hospice doctor on 6/22/23. R1 is currently on comfort care under hospice at the facility.
LPA requested copies of physician's report dated 6/22/23, hospice care plan dated 2/2/23, verbal orders dated 6/27/23, physician's order dated 6/26/23 and 6/29/23, hospice communication sheet dated 6/22, 6/26,6/27,6/29/23, x-ray interpretation dated 6/28/23, hospital discharge dated 1/28/22, hospice initiation letter dated 2/2/23, and unusual incident report dated 6/29/23, appraisal/needs and service plan dated 6/22/23, advance health care directive dated 3/1/10, and medication sheet for July 2023.

Facility staff is following hospice care plan and healthcare designated agent's request to provide comfort care for R1 and is currently updating appraisal/needs and service plan.

No deficiencies were noted during this visit.

Exit interview was conducted with Virginia Garcia 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: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023
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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