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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880801
Report Date: 03/25/2022
Date Signed: 03/25/2022 12:25:03 PM


Document Has Been Signed on 03/25/2022 12:25 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



FACILITY NAME:JASMIN TERRACE AT YUCCA VALLEYFACILITY NUMBER:
361880801
ADMINISTRATOR:MICHAEL GARCIAFACILITY TYPE:
740
ADDRESS:55425 SANTA FE TRAILTELEPHONE:
(760) 365-0887
CITY:YUCCA VALLEYSTATE: CAZIP CODE:
92284
CAPACITY:85CENSUS: 63DATE:
03/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator Michael GarciaTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility 03/25/2022 at 10:00 AM to follow up on a Death Report regarding Resident 1 (R1) death at the facility. LPA Brown identified herself to Administrator Michael Garcia, who was also advised of the purpose of the visit.

On 03/22/2022 Community Care Licensing Department (CCLD) was notified of the death of Resident 1 (R1) last 03/21/2022. LPA Brownrequested the following documents:

-ID/Emergency information
-Admission Agreement
-Physician's report
-Psychiatric and Medical notes/orders
-Resident Appraisal
-Medication records
-Weight record


LPA Brown also requested additional documentation be sent to CCLD; such as, the Coroner's Report, Police Report, and a Death Certificate upon availability.

An exit interview was conducted where this report (LIC809) was discussed, and a copy was provided to the Administrator Michael Garcia at the conclusion of the visit.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022
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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