306001102-2-28-2024-22-AS-ARJR-D2VR2U-20240228113853

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306001102
Report Date: 02/28/2024
Date Signed: 02/28/2024 11:39:00 AM

Document Has Been Signed on 02/28/2024 11:39 AM - 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 RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	JASMIN'S CARE HOME		FACILITY NUMBER:	306001102
ADMINISTRATOR:	MANUEL G. PEREZ		FACILITY TYPE:	740
ADDRESS:	2817 SAN JUAN LANE		TELEPHONE:	(714) 662-0625
CITY:	COSTA MESA	STATE: CA	ZIP CODE:	92626
CAPACITY:	6	CENSUS: 4	DATE:	02/28/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:52 AM
MET WITH:	Laura Perdomo-Caregiver, Manuel Perez-Administrator		TIME COMPLETED:	11:54 PM

NARRATIVE

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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by Caregiver Laura Perdomo. Administrator (AD) Manuel Perez arrived shortly after.

For today’s visit, LPA observed a total of 3 residents in care and 1 staff member on duty.

LPA observed the Administrator's Certificate for facility AD Manuel Perez which expires on 01/09/2025.

LPA Ramirez toured the interior and exterior portions of the facility with AD Perez. The facility is a single level structure and is licensed for 6 non-ambulatory residents. For this visit, there are a total of 3 residents in care. There are a total of 4 bedrooms, of which 4 are private resident bedrooms. LPA Ramirez toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of 2 restrooms. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested between 106.7-108.1 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguisher was charged, mounted and located in the hallway.

CONTINUED ON LIC809-C...

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024

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 02/28/2024 11:39 AM - 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: JASMIN'S CARE HOME	FACILITY NUMBER: 306001102
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

HSC

1569.605

Other Provisions

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. 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 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/29/2024
	Plan of Correction
1 2 3 4	Licensee to provide valid liability insurance by POC due date.

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: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024

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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: JASMIN'S CARE HOME	FACILITY NUMBER: 306001102
	VISIT DATE: 02/28/2024

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LPA Ramirez observed the emergency disaster and evacuation plan, which is posted by the dining room. Facility had back-up emergency food and water supply, located in the garage. LPA observed that First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to residents in care.

For the exterior portion, LPA Ramirez observed a canopy with patio furniture, and the grounds were free of any hazards. There are 2 gates in the backyard, which both were self-closing and self-latching. In the backyard LPA observed a fenced and empty jacuzzi.

LPA reviewed four resident files and two staff files. LPA interviewed residents and staff present.

For today's visit deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

An exit interview was conducted with AD Perez.

A copy of this report was provided at the time of exit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024

LIC809 (FAS) - (06/04)

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