197607655-3-26-2024-28-AS-MGFS-D3QUG6-20240326153350

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607655
Report Date: 03/26/2024
Date Signed: 03/26/2024 03:34:01 PM

Document Has Been Signed on 03/26/2024 03:34 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 MOLINO		FACILITY NUMBER:	197607655
ADMINISTRATOR:	VIRGINIA GARCIA		FACILITY TYPE:	740
ADDRESS:	245 S. EL MOLINO AVE.		TELEPHONE:	(626) 578-0460
CITY:	PASADENA	STATE: CA	ZIP CODE:	91101
CAPACITY:	206	CENSUS: 140	DATE:	03/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:21 AM
MET WITH:	Lori Lackey - Assistant Administrator		TIME COMPLETED:	03:45 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 annual visit at the facility using the inspection CARE tool. LPA Flores met with Lori Lackey 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 17 residents on hospice. Facility is a two story building in a residential area which consist of shared bedrooms, several common areas, a commercial kitchen, and a courtyard. 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. Today's visit consisted of a tour of the facility (Physical Plant Domain) with Lori Lackey and medication review. LPA observed the following: First floor common areas: Lobby, visitation room, dining rooms, activity room all have sufficient space with furniture in good repair, and fireplaces are covered. Commercial kitchen was observed clean, in good repair, and food supplies were observed sufficient for at least 2 days of perishables and 7 days of non-perishables. Seven (7) random bedrooms were observed in the first floor; each room is furnished with the required furniture, with sufficient lighting, and bedding supplies. Bathrooms were observed in working condition and in room #107 a bottle of disinfectant spray was observed under the bathroom cabinet accessible to the resident. Water temperature was tested between 89.7 - 110.3 degrees F., which is not within the required 105-120 degrees F. (room#114 at 103.8 F., room #119 at 89.7 F., room #134 at 100.5 F.) Second floor: Seven (7) random bedrooms were observed each room is furnished with the required furniture, with sufficient lighting, and bedding supplies. Bathrooms were observed in working condition. Water temperature was tested between 100.4 - 114.4 degrees F., which is not within the required 105-120 degrees F. (room #259 at 100.4 F., room #240 at 104.1 F., room #204 at 90.3 F.)(CONTINUED LIC809C)

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

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 4

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
	VISIT DATE: 03/26/2024

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
26
27
28
29
30
31
32

Second floor: dining room has sufficient furniture and in good repair. Medication room was observed inaccessible to the residents.
Each egress system exit door was tested in working condition except for the egress system in the exit gate to the left of the building which exits to El Molino. The gate was observed tied with a rope to hold closed.

Medication was reviewed for 14 residents.

LPA will return at a different time to continue the annual visit and complete the other domains.

Deficiencies were noted during this visit 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 Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 03/26/2024 03:34 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: 03/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in disinfectant spray was observed in room #107's bathroom cabinet accessible to the resident which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 03/27/2024
	Plan of Correction
1 2 3 4	Assistant administrator removed disinfectant spray from the room during the visit. Administrator will schedule in-service training to staff and family regarding section 87309 by 3/27/24. Administrator will submit a copy of sign-in log, agenda with description of training and duration of training by 4/2/24.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

LIC809 (FAS) - (06/04)

Page: 3 of 4

Document Has Been Signed on 03/26/2024 03:34 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: 03/26/2024

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in water temperature in the following room tested as follow: room#114 at 103.8 F., room #119 at 89.7 F., room #134 at 100.5 F. room #259 at 100.4 F., room #240 at 104.1 F., room #204 at 90.3 F., which is not within 105-120 degrees F. which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/02/2024
	Plan of Correction
1 2 3 4	Administrator wil adjust water temperature and will test water temperature in the rooms above for 7 days twice a day will maintain a temperature log and will submit the log on POC due date 4/2/24.

Type B

Section Cited

CCR

87303(a)

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in exit gate to El Molino street on the left of the building egress system is not working and was observed tied with a rope which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/05/2024
	Plan of Correction
1 2 3 4	Administrator will contact proper agency for repairs and will submit invoice of repairs by POC due date 4/5/24.

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 Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

LIC809 (FAS) - (06/04)

Page: 4 of 4