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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880801
Report Date: 07/27/2020
Date Signed: 09/09/2020 09:48:38 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:JASMIN TERRACE AT YUCCA VALLEYFACILITY NUMBER:
361880801
ADMINISTRATOR:MICHAEL GARCIAFACILITY TYPE:
740
ADDRESS:55425 SANTA FE TRAILTELEPHONE:
(951) 818-7250
CITY:YUCCA VALLEYSTATE: CAZIP CODE:
92284
CAPACITY:85CENSUS: 50DATE:
07/27/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Virginia GarciaTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Kathleen Wiggins conducted an announced pre-licensing video conference inspection to the facility due to COVID-19. LPA met with Virginia Garcia. Currently there are 50 residents in care.

The facility is licensed for 85 non-ambulatory residents, including 10 bedridden, with a Hospice Waiver for 10. The facility is approved for Delayed Egress. The facility is operating in the capacity and conditions approved by community care licensing. LPA inspected a sample of resident rooms and no immediate hazards were identified in the rooms. All rooms were clean and free of clutter. During the tele-visit, LPA had the emergency alert system tested. Staff responded to the alert in a sufficient time frame. LPA had hot water tested in three residents rooms as follows: Room # 104 water temperature reading 109.5 degrees, room # 112 water temperature reading 110.9, room #212 water temperature reading 113.1.

Non perishable and perishable food is sufficient for number of residents in care. Food is being prepared and stored properly. Facility has a variety of food available for residents. LPA inspected the dining areas. Menus are posted in the dining area of the facility. No chemicals or toxins were observed accessible to residents in care. LPA observed first aid kits present in the facility. Medications are centrally located and secured. Outdoor spaces were observed to have shaded space in the common areas.


Fire extinguishers are posted in common areas throughout the facility

An exit interview was conducted, and a copy of this report was reviewed and provided to Ms. Garcia via email to obtain signature.

Receipt of report was confirmed.
SUPERVISOR'S NAME: Leslie MendivelesTELEPHONE: (951) 248-2222
LICENSING EVALUATOR NAME: Kathleen WigginsTELEPHONE: (951) 205-7142
LICENSING EVALUATOR SIGNATURE:

DATE: 07/27/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/27/2020
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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