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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607655
Report Date: 03/28/2024
Date Signed: 03/28/2024 03:00:06 PM


Document Has Been Signed on 03/28/2024 03:00 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: 140DATE:
03/28/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:31 AM
MET WITH:Lori Lackey - Assistant Administrator TIME COMPLETED:
03:15 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 (LPA) Mary Flores conducted an unannounced case management visit for an annual continuation by using the CARE inspection tool. LPA met with Denise Miller Office Coordinator an explained the reason of the visit. On 3/26/24 LPA Flores completed The CARE tool domains of Physical Plant/Environmental Safety and Food Service.

During today's visit LPA reviewed 10 resident files and 10 staff files. LPA observed Appraisal Needs and Service Plan for resident #6 (R6) was last updated on 9/1/22 and #9 (R9) was last updated 1/6/23 which was not updated within the last 12 months.

LPA reviewed Infection Control Plan last reviewed on 3/1/24, Emergency Disaster Plan last reviewed on 2/6/24 , Fire drill log (last fire drill conducted on 3/8/24), In-Service training file. LPA observed 20 hours of training. However, in service training did not include 4 hours of hospice care, postural support, and restricted health conditions/health services.

LPA conducted interviews with 5 residents and 5 staff.

The following CARE tool domains were completed during this visit: Infection Control, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Planned Activities, Incidental Medical and Dental, Resident Records/Incident Reports, Disaster Preparedness, Residents with Special Health Needs.

Deficiencies were noted in LIC 809D per Title 22 Regulations.

Exit interview was conducted with Lori Lackey 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: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
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 03/28/2024 03:00 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: 03/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.696(a)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in staff training did not include training on postural support, hospice care, restricted conditions or health services which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/10/2024
Plan of Correction
1
2
3
4
Administrator will schedule training with proper training services and will provide a copy of 4 hours of in-services training on postural support, hospice care, restricted conditions or health services log (certificate) to the department by POC due date 4/10/24.
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in Appraisal Needs and Service Plan for resident #6 (R6) was last updated on 9/1/22 and #9 (R9) was last updated 1/6/23. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/04/2024
Plan of Correction
1
2
3
4
Administrator will update the appraisal needs and service plan for R6 and R9 and will submit a copy to the department by POC due date 4/4/24.
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: 03/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2