198603122-4-5-2024-28-AS-EZAA-D42QQE-20240405122213

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603122
Report Date: 04/05/2024
Date Signed: 04/05/2024 12:22:57 PM

Document Has Been Signed on 04/05/2024 12:22 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:	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:	04/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Lualhati Hilado - Caregiver		TIME COMPLETED:	12:47 PM

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Licensing Program Analysts (LPAs) Erik Zaragoza and Daniel Konishi conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to Moris Shockley, President and CEO of Hollenbeck Palms, and was granted entrance. Administrator Diana Medina arrived shortly thereafter. There are one-hundred and sixty-two (162) residents currently living in the facility.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed. Infection Control Plan will be submitted to LPA within seven (7) days.

Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood. It is licensed for a capacity of six (6) residents, all of which may be non-ambulatory, four (4) may be receiving hospice, and one (1) of which may be bedridden. It has four (4) resident rooms, a dining room which also contains the facility’s washing and drying machines, a kitchen, two (2) residents bathrooms of which Restroom #1 had a hot water temperature reading at 109.8 Degrees F and Restroom #2 had a hot water temperature reading of 107.1 Degrees F, a backyard patio which contained a shaded area for residents, and also a detached garage that functions as the facility’s storage and holds additional food and incontinence supplies. Cleaning supplies and chemicals are kept locked in a cabinet in the kitchen.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024

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 04/05/2024 12:22 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: JASMINES RESIDENTIAL CARE FOR ELDERLY	FACILITY NUMBER: 198603122
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/05/2024

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 record review, the licensee did not comply with the section cited above in 4 out of 4 residents, because the plan of operation was not held at the facility for review, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Administrator is to ensure that the Plna of Operation is held at the facility at all times. Administrator is to email the Plan of Operation to LPA by POC due date.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 4 our of 4 residents, because the last documented disaster drill was conducted in 2020, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Administrator is to ensure that disaster drills are documented at least once every 3 months. Administrator is to hold a drill and submit documentation of the drill to LPA by the POC due date.

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024

LIC809 (FAS) - (06/04)

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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: JASMINES RESIDENTIAL CARE FOR ELDERLY	FACILITY NUMBER: 198603122
	VISIT DATE: 04/05/2024

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· The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. The facility has two (2) fully charged fire extinguisher located on both floors of the facility, including the basement. There were no sharp objects that were left accessible to residents.
· Water temperature readings measured between the required 105 - 120 degrees Fahrenheit.
Operational Requirements:
· The facility did not have a Plan of Operation on record, administrator was asked to provide this to LPA at a later date.

· Fire clearance was approved by LA County Fire Department for a capacity of six (6) residents, all of which may be non-ambulatory, four (4) may be receiving hospice, and one (1) of which may be bedridden.

· Care and supervision to meet the clients’ needs was observed.
Staffing:

· A total of seventeen (17) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Five (5) staff files were reviewed for criminal background clearance and training.

· Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training.
Resident Rights/Information:

· Physician orders were reviewed for four (4) resident files.

· Medications were also reviewed for four (4) residents.

Resident Records/Incident Reports:

· Four (4) resident files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024

LIC809 (FAS) - (06/04)

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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: JASMINES RESIDENTIAL CARE FOR ELDERLY	FACILITY NUMBER: 198603122
	VISIT DATE: 04/05/2024

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Food Service:

· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

Incident Medical and Dental:

· All residents have an Appraisal/Needs and Services Plan on file.

· Staff training was on file.

Disaster Preparedness:

· Emergency and Disaster Plan was publicly posted and found within the facility.

· An emergency and disaster drill was last documented in 2020.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit are documented on the LIC809Ds. Exit interview held and a copy of the report along with appeal rights were provided.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024

LIC809 (FAS) - (06/04)

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