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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607655
Report Date: 04/23/2024
Date Signed: 04/23/2024 02:18:32 PM


Document Has Been Signed on 04/23/2024 02:18 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: 143DATE:
04/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:27 PM
MET WITH:Lori Lackey - Assistant Administrator TIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Mary FLores conducted an unannounced case management visit regarding incident report submitted to the facility on LPA met with Lori Lackey and Rocio Gonzalez and explained the reason for the visit.

On 4/16/24 the department received incident report which reports on 4/13/24 Resident #1(R1) jumped over the fence and left the facility. Staff went out to search for R1 and police was contacted. R1 was found by someone who lives in the neighborhood on Oak Knoll St., the individual called 911 after witnessing R1 fall down. R1 was then transported to the hospital. On 4/19/24 LPA contacted Lori Lackey and requested physician's report, needs and care plan, hospital discharge documents for R1.

During this visit LPA reviewed the documents and tour the facility.
Per the incident report R1 jumped over the fence in the courtyard that faces El Molino St. Fence at 1:59pm. The fence is over 6ft in high. Staff noted R1 missing at 2:10pm. Per physician's report dated: 9/8/23 R1 cannot leave the facility unattended due to cognitive skills. Per Individual Service Plan dated 12/5/23 R1 has a history of wandering and leaving unassisted. Needs and Service Plan dated 4/22/24 notes R1's wandering behavior and staff will provide monitoring due to wandering. Medication sheet shows medication was adjusted on 4/23/24. Admission agreement shows R1 was admitted on 4/9/24. Per Assistant administrator R1 is still assimilating to the facility, a psychological evaluation was conducted on 4/22/24 and adjustment in medication has been done by the physician.

Deficiencies are noted on 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: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024
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 04/23/2024 02:18 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: 04/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/24/2024
Section Cited
CCR
87468.2(a)(4)

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87468.2 Additional Personal Rights... (a) ...residents...shall...: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.
This requirement is not met as evidence by:
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 Administrator will update needs and care plan to note the frequency of supervision provided and accomodations to assist R1 with assimilating to the environment by POC due date 4/24/24.
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Based on documents review and interviews conducted facility did not ensure R1 left the facility unattended which poses an immediate 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: 04/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024
LIC809 (FAS) - (06/04)
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