361880801-2-25-2022-18-AS-EMAN-CCXV2K-20220328160317

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880801
Report Date: 02/25/2022
Date Signed: 02/25/2022 12:20:23 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/12/2021 and conducted by Evaluator Melody Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20211012172650

FACILITY NAME:	JASMIN TERRACE AT YUCCA VALLEY		FACILITY NUMBER:	361880801
ADMINISTRATOR:	MICHAEL GARCIA		FACILITY TYPE:	740
ADDRESS:	55425 SANTA FE TRAIL		TELEPHONE:	(760) 365-0887
CITY:	YUCCA VALLEY	STATE: CA	ZIP CODE:	92284
CAPACITY:	85	CENSUS: 60	DATE:	02/25/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator Michael Garcia		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Facility has no activities for residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility 02/25/2022 at 09:15 AM for the purpose of delivering the findings to the above allegation. LPA Brown met with staff Priscilla Soto. LPA Brown explained the purpose of the visit and was granted entry. Administrator Michael Garcia arrived during the visit.

The investigation was conducted by LPA Brown. LPA toured the facility, conducted interviews, and reviewed facility files. The allegation indicates that facility has no activities for residents. Interviews with staffs and residents indicated that the facility has no activities for residents. LPA Brown interviewed five (5) residents and four (4) staff. 3 out of 5 residents reported that facility do not have activities for the residents and 2 residents are not oriented and unable to answer LPA questions. LPA Brown interviewed 4 staff. 2 out of 2 staff stated that the facility do not have activities for residents.

*** continuation on LIC 9099C***

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 18-AS-20211012172650

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/25/2022

NARRATIVE

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Based on resident and staff interviews and record reviews, LPA determined that the allegation Facility has no activities for residents is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted with Administrator Garcia where a copy of this report (LIC 9099) along with LIC 9099-D and Appeal Rights were discussed and provided.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 18-AS-20211012172650

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/25/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/04/2022 Section Cited CCR 87705(c)(7)	1 2 3 4 5 6 7	87705 Care of Persons with Dimentia (c) Licensees who accept and retain residents with dementia ... (7) An activity program shall address the needs and limitations of residents with dementia and include ... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee will submit List of Activities and Activities Schedule for residents in care by POC due date to Community Care Licensing Department (CCLD) or LPA. Licensee will submit Statement of Understanding for CCR 87705(c)(7) to LPA Brown by POC due date.
	8 9 10 11 12 13 14	Based on observations, interviews and record review, the licensee did not provide activities for residents at the facility, which poses a potential Health, Safety, or Personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/12/2021 and conducted by Evaluator Melody Brown

COMPLAINT CONTROL NUMBER: 18-AS-20211012172650

FACILITY NAME:	JASMIN TERRACE AT YUCCA VALLEY		FACILITY NUMBER:	361880801
ADMINISTRATOR:	MICHAEL GARCIA		FACILITY TYPE:	740
ADDRESS:	55425 SANTA FE TRAIL		TELEPHONE:	(760) 365-0887
CITY:	YUCCA VALLEY	STATE: CA	ZIP CODE:	92284
CAPACITY:	85	CENSUS: 60	DATE:	02/25/2022
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator Michael Garcia		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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9

Residents are locked in their rooms.
Staff do not assist residents or are sleeping.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
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9
10
11
12
13

Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility 02/25/2022 at 09:15 AM for the purpose of delivering the findings to the above allegations. LPA Brown met with staff Priscilla Soto. LPA Brown explained the purpose of the visit and was granted entry. Administrator Michael Garcia arrived during the visit.

The investigation was conducted by LPA Brown. LPA toured the facility, conducted interviews, and reviewed facility files. The first allegation indicates that residents are locked in their room. During the investigation, LPA Brown was not able to obtain evidence to corroborate the allegation. LPA Brown interviewed five (5) residents and four (4) staff and interviews with staff and residents indicated that residents are not locked in their rooms.

*** continuation on LIC 9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 18-AS-20211012172650

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/25/2022

NARRATIVE

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3 out of 5 residents stated that they are not locked in their room and 2 residents are not oriented and unable to answer LPA questions. LPA Brown interviewed 4 staff. 4 out of 4 staff stated that they do not lock residents in their room.

The second allegation indicates that staff do not assist residents or are sleeping. Interviews with staff and residents also indicated that the facility staff assist residents and facility staff are not sleeping. 3 out of 5 residents stated that facility staff assist them if they need help, and no staff were found sleeping and 2 residents are not oriented and unable to answer LPA questions. LPA Brown interviewed 4 staff. 4 out of 4 staff stated that they assist residents if they need help and they do not sleep while at work.

Based on the information obtained and observation, there is not enough evidence to state residents are locked in their room (allegation #1) and staff do not assist residents or are sleeping (allegation # 2). Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time.

An exit interview was conducted, and a copy of this report (LIC 9099) was discussed and provided to Administrator Michael Garcia.

SUPERVISOR'S NAME: Efren Malagon	TELEPHONE: (951) 248-0337
LICENSING EVALUATOR NAME: Melody Brown	TELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:	DATE: 02/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5