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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 300606032
Report Date: 11/08/2023
Date Signed: 11/08/2023 03:40:47 PM

Document Has Been Signed on 11/08/2023 03:40 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:JASMINE GARDENFACILITY NUMBER:
300606032
ADMINISTRATOR:HALAHAN, ELIZABETHFACILITY TYPE:
735
ADDRESS:1329 N. JASMINE ST.TELEPHONE:
(714) 776-8582
CITY:ANAHEIMSTATE: CAZIP CODE:
92801
CAPACITY: 8CENSUS: 8DATE:
11/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Administrator Liz HalahanTIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived for an unannounced visit for the purpose of conducting a required annual inspection. LPA was greeted and granted entry into facility by DSP Gisella Montalvo. House Manager Gisella Salgado and Administrator (AD) Liz Halahan joined the visit at approximately 1:00pm

The facility is a one-story home with five resident bedrooms, three resident bathrooms, kitchen, dining room, den, staff room/staff bathroom, front yard and detached garage. LPA noted that all residents were away at day program upon arrival. The facility is on the corner of its street with two entrance doors. There is no backyard, however the facility has shaded seating areas in the front yard. Facility appears clean and sanitary. All residents rooms had required elements, including bed, chair, closet space and ample lighting. Restrooms are stocked with soap and paper towels and have hand washing postings. Hot water measured at 111 degrees Fahrenheit in the bathroom nearest the kitchen, 109 degrees Fahrenheit in the bathroom across from the laundry appliances and 109.9 degrees Fahrenheit in the bathroom accessible from the shared resident room at the back of the house. LPA observed facility has emergency food and water supply. LPA observed smoke/CO2 detectors to be operational. LPA observed the Fire Extinguisher to be charged. Service tag indicated it was last serviced on 7/25/2023. Medication, first aid kit and facility files are stored in a locked cabinet in the dining area. LPA reviewed four of the eight resident files, each contained required documentation. LPA reviewed P&I with administrator. P&I money reviewed was accounted for and documented properly. LPA interviewed three residents upon their return from day program. Upon their return, LPA observed residents talking to the staff about their respective days at day program and wanting to assist with the LPA's inspection. The residents appeared to be comfortable at the facility.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was provided to the administrator.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Dwayne L Mason
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2023
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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