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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880801
Report Date: 10/08/2020
Date Signed: 10/08/2020 04:08:55 PM

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: 52DATE:
10/08/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:24 PM
MET WITH:Administrator Michael Garcia and Jennifer Levesque TIME COMPLETED:
04:00 PM
NARRATIVE
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On 10/08/20 Licensing Program Analyst (LPA) Javina George contacted the facility via telephone to conduct an unannounced case management incident visit via face time. LPA George met with Administrator Michael Garcia and Assistant Administrator Jennifer Levesque and explained the purpose of the visit was due to the SOC 341 that was submitted to the office.
At 1:24pm LPA George inquired as to what the outcome of the investigation was with Administrator Michael and Assistant Jennifer. Jennifer explained that there was no concrete evidence to determine if in fact S1 abused resident #1 (R1). Per Jennifer R1 stated that S1 is not nice to them, but did not elaborate any further. Jennifer explained that the investigation had been concluded and S1 returned back to work on 10/5/20, after a four day suspension. Both Jennifer and Michael stated that this is an isolated incident for S1 and shared what measures were now being implemented with S1. LPA George requested a copy of the signed agreement for S1 and was received via email at 3:19pm. (Plan of Correction, (POC) has been cleared. The agreement states that if S1 violates the agreement employment would be terminated.

At 130pm LPA George conducted a tour of the facility. LPA observed the required Covid-19 postings and proper sanitization supplies. The facility entry and passage ways were free from obstruction. The kitchen was in tact and all required repairs had been made. All staff observed had on masks. LPA obtained contact information for Staff 1 (alleged abuser) and staff 2 (witness) (S1, S2) and conducted interviews.

At 1:38pm LPA George met with R1 whom stated that S1 is not nice to her, because S1 is always yelling at her. R1 stated that S1 tipped R1 while R1 was in their wheelchair while in the bathroom. R1 stated that, was the extent of the incident.
LPA George conducted an interview with S1, 1:38pm-1:44pm. S1 denied having intentionally causing any harm to R1, and wanted to get R1 into the shower.

*Continued on 809C
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 VALLEY
FACILITY NUMBER: 361880801
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/09/2020
Section Cited

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80072 Personal Rights
(a)Except for children’s residential facilities, each client shall have personal rights which include...
(3)To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning. This requirement is not met as evidenced by:
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Based on observations, interviews and record review, the administrator did not ensure that 1 out of 52 resident's was free from unusual punishment, infliction of pain and intimidation which poses an immediate Health, Safety or Personal Rights risk to person's in care.
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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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:
DATE: 10/08/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 VALLEY
FACILITY NUMBER: 361880801
VISIT DATE: 10/08/2020
NARRATIVE
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Based on today's case management incident visit, deficiencies were observed and cited according to California Code of Regulations, Title 22, Division 6 section 80072(a)(1) and listed on the LIC 809D.

An exit interview was conducted and a copy of this report, 809C, 809D, 811 (confidential names list) and appeal rights were provided to Administrator Michael Garcia.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2020
LIC809 (FAS) - (06/04)
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