198603122-5-18-2026-28-AS-EZAA-DU7UTC-20260518155144

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603122
Report Date: 05/18/2026
Date Signed: 05/18/2026 03:52:57 PM

Document Has Been Signed on 05/18/2026 03:52 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/ DIRECTOR:	MAGHIRANG, LEVITA H		FACILITY TYPE:	740
ADDRESS:	10407 PAYETTE DR		TELEPHONE:	(562) 943-3054
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90603
CAPACITY: 6		CENSUS: 3	DATE:	05/18/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:36 AM
MET WITH:	Raiza Juan - Caregivers		TIME VISIT/ INSPECTION COMPLETED:	03:45 PM

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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1-year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Rui Jen Huang, caregiver for the facility, and explained the purpose of the visit. Administrator Levita Maghirang arrived shortly thereafter.

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 plan is on file.

Physical Plant/Environment Safety:

· The facility is a single-story home located in a residential neighborhood. The facility consists of four (4) resident bedrooms,a living room, a kitchen, a dining room which contains the washer and dryer for the facility, a detached garage which contains extra food supplies, a backyard with a shaded area, two (2) resident restrooms which measured 105.1 and 105.5 degrees Fahrenheit respectively. The facility was observed to be in good repair. Two (2) fully charged fire extinguishers are kept on the premises.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 05/18/2026 03:52 PM - It Cannot Be Edited

Created By: Erik Zaragoza On 05/18/2026 at 03:20 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 05/18/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87211(a)(1)

Reporting Requirements

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in two (2) residents, because the death report for Resident #1 and incident report for Resident #2's hospitalization was not received by the licensing agency, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/12/2026
	Plan of Correction
1 2 3 4	Administrator is to ensure that incident and death reports are submitted to the department in the appropriate time frames at all times. Administrator shall fax the incident report and death report to LPA and submit facility's plan on how incident and death reports will be sent to LPA by the POC due date.

Type B

Section Cited

CCR

87608(a)(3)

Postural Supports

(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident's record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review and observation, the licensee did not comply with the section cited above in 3 out of 3 residents, because all residents have half-rails on their beds however they do not have physician orders in their records, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 06/12/2026
	Plan of Correction
1 2 3 4	Administrator is to ensure that physician orders for half rails are obtained for all residents and kept in their file at all times. Administrator is to obtain the physician orders for the half-rails for the 3 residents and submit them 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.

	David Sicairos
NAME OF LICENSING PROGRAM MANAGER:

	Erik Zaragoza
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026

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: 05/18/2026

NARRATIVE

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Operational Requirements:
· Fire clearance was approved by LA County Fire Department for a capacity of six (6) non-ambulatory residents, one (1) bedridden resident, and a hospice waiver approved for four (4) residents.
· Care and supervision to meet the clients’ needs was observed.

Staffing:

· Four (4) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Four (4) staff files were reviewed for criminal background clearance and training.

· All Four (4) staff records have a health screening with a Tuberculosis clearance, First Aid/CPR trainings that are active, and required annual trainings.

Resident Rights/Information:

· Physician orders were reviewed for three (3) resident files.

· Medications were also reviewed for three (3) residents.

Resident Records/Incident Reports:

· Three (3) 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.

· During visit it was discovered that Resident #1 had passed away two (2) weeks ago, and Resident #2 was hospitalized for pneumonia on 5/5/2026, however incident reports were not received by the licensing agency for these incidents.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026

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: 05/18/2026

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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 are assisted with medication management by staff.

Disaster Preparedness:

· Emergency and Disaster Plan (LIC610E) was posted in the facility and LPA obtained a copy.

· The last emergency and disaster drill was conducted on 4/3/2026.

Planned Activities:

· Sufficient Space is provided to accommodate both indoor and outdoor activities.

· Sufficient equipment and supplies are provided to meet the requirements of the activity program.

Residents with Special Health Care Needs

· There is an adequate number of staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her appraisal.

· LPA observed that there all three (3) residents have half-bed rails on their beds, however there is no physician’s order in their files for the half-rails.

Per California Code of Regulations, Title 22, and California Health and Safety Code, the deficiencies observed during the visit is documented on the LIC809D page. Exit interview held and a copy of the report along with appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Erik Zaragoza
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2026

LIC809 (FAS) - (06/04)

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