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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603122
Report Date: 06/06/2022
Date Signed: 06/06/2022 04:27:09 PM


Document Has Been Signed on 06/06/2022 04:27 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:JASMINES RESIDENTIAL CARE FOR ELDERLYFACILITY NUMBER:
198603122
ADMINISTRATOR:MAGHIRANG, LEVITA HFACILITY TYPE:
740
ADDRESS:10407 PAYETTE DRTELEPHONE:
(562) 943-3054
CITY:WHITTIERSTATE: CAZIP CODE:
90603
CAPACITY:6CENSUS: 3DATE:
06/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Administrator Levita Maghirang. TIME COMPLETED:
01:00 PM
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Licensing Program Analyst Jose Villalobos conducted an unannounced Annual Inspection for Domain focused on Inspection Control. LPA was assisted by Administrator Levita Maghirang.

As a part of the inspection, LPA used the inspection tool, reviewed (3) client records, (3) staff files, and (3) client medications. Currently the facility has (3) clients of which (3) are non-ambulatory. The facility is licensed as a Residential Care Facility for the Elderly. The home is a (4) bedroom and (2) bathroom single story home located in a residential neighborhood. The home was adequately furnished, including the dining room, living room, inside patio.. Bedrooms #1-2 are for 1 resident each. Rooms #3-4 are for up to (2) residents each. Each bedroom had the required, furniture, fixtures, equipment and supplies. Including complete set of bedding, linen supply, hygiene supply, storage space, lighting. The smoke detectors and the carbon monoxide detector were tested and are operational. Medications, cleaning solutions, toxins, knives are locked and inaccessible to clients. Hot water temperature measured within regulation. First aid kit observed. Food Supply was observed. Outside shaded activity area is available for resident use. Yard is free of debris. Exits and passageways are free of obstructions. Facility is following Covid-19 guidelines and recommendations.

Infection control domain completed and there were no deficiencies. An exit interview was conducted and a copy of this report was provided to Administrator Levita Maghirang.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose VillalobosTELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:
DATE: 06/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/06/2022
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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