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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607655
Report Date: 04/22/2021
Date Signed: 04/26/2021 03:15:07 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 109DATE:
04/22/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Virginia Garcia - AdministratorTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mary Flores, Licensing Program Manager(LPM) Rebecca Orendain, Regional Manager (RM) Araceli Ramirez, and Pasadena Public Health Department Nurse (PPHD - HEFN) Whitney Frame conducted an office visit regarding documentation provided to PPHD on a timely manner. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today's visit was conducted via Microsoft Teams meeting with Virginia Garcia Administrator and Lori Lackey Assistant Administrator.

The following was discuss during the meeting:
  • RM Ramirez discussed concern regarding documentation for new admissions not being submitted to PPHD timely and consistently.
  • Facility is currently allowed to have new admission from Assistant Living Waiver (ALW) program.
  • Facility has been moved to surveillance testing - testing staff once a week and 50% of residents once a week.
  • Per PPHD-HEFN Frame facility is consistent with submitting lab test for all testing.
  • Per PPHD- HEFN Frame facility is to submit 2 out of 3 documents currently required for admission; ALW Verification of Approval, Vaccination Card, and/or Declination of Vaccination before admission, the day of, or 24 hours after admission.
  • PPHD - HEFN Frame stated that the facility is responsible for submitting the documents to the department upon any new admissions.
  • RM Ramirez follow up with reminding Administrator that due to history and previous citations for not submitting documentation, subsequent citations will be assess if facility does not comply with submitting documents.

Exit interview was conducted with Virginia Garcia Administrator telephonically, and a copy of the report was email for signature.
SUPERVISOR'S NAME: Rebecca OrendainTELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Mary G FloresTELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2021
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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