198603122-5-9-2023-28-AS-JVIS-CRNURZ-20230509154935

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603122
Report Date: 05/09/2023
Date Signed: 05/09/2023 03:49:54 PM

Document Has Been Signed on 05/09/2023 03:49 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 ELDERLY		FACILITY NUMBER:	198603122
ADMINISTRATOR:	MAGHIRANG, LEVITA H		FACILITY TYPE:	740
ADDRESS:	10407 PAYETTE DR		TELEPHONE:	(562) 943-3054
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90603
CAPACITY:	6	CENSUS: 4	DATE:	05/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:05 AM
MET WITH:	Administrator Levita Maghirang		TIME COMPLETED:	11:30 AM

NARRATIVE

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Licensing Program Analyst (LPA) Jose Villalobos, conducted a required annual inspection using the Inspection Tool. LPA met with Administrator Levita Maghirang and the purpose of the visit was discussed.

As a part of the inspection toured the physical plant. LPA conducted a review of four (4) resident files and four (4) staff files. LPA conducted a review of medications for four (4) residents. All medications and records are maintained in compliance with label instructions and centrally stored. The home consists of (4) resident bedrooms (2) bathrooms. (1) living rooms, kitchen, dining area, laundry area. A garage is being used for storage for supplies. During the inspection LPA observed the resident rooms with required furniture, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. LPA observed fully stocked bedding and towel in closets. All bathroom fixtures are in working condition. LPA observed sufficient bedding, linens, and toiletries are accessible to residents. Water temperature properly measured within Title 22 regulations. LPA observed perishable and non-perishable food supply. LPA tested facility Carbon Monoxide and Smoke Detectors and are working properly. The facility has (2) Fire Extinguisher fully charged. All disinfectants, cleaning solutions and toxins were in locked cabinets. Medications are centrally stored in locked cabinet inaccessible to residents. Facility first aid kit was checked and in compliance. Outside grounds were toured and no bodies of water were observed. Fireplace closed and inaccessible to residents. All Exits/ Walkways around the home were free of debris and hazards. The facility has a functional operating landline telephone. Required postings observed.

Inspection tool was completed and LPA observed a deficiency; therefore, a citation is being issued per Title 22 Regulations. Please see LIC 809-D

Exit interview was conducted, and a Facility Evaluation Report was provided. Appeal rights discussed and provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

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 05/09/2023 03:49 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: JASMINES RESIDENTIAL CARE FOR ELDERLY	FACILITY NUMBER: 198603122
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/09/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87208(a)

Plan of Operation

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above as Plan of Operation file was not observed in the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/19/2023
	Plan of Correction
1 2 3 4	Licensee / Administrator will create Binder with Plan of Operation to keep on file by POC due date. LPA to be provided with picture image of file being on site of the facility.

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: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC809 (FAS) - (06/04)

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