361880801-7-16-2021-18-AS-JESL-CFWRXB-20220701132427

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880801
Report Date: 07/16/2021
Date Signed: 07/16/2021 01:54:27 PM

Substantiated

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
07/15/2021 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210715124753

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:	07/16/2021
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Administrator Michael Garcia		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Facility has a cockroach infestation.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javina George arrived unannounced at the facility to commence an investigation and deliver findings for the allegation listed above. LPA was greeted and granted entry by Director of Nutrition Services Maria Molina and explained the purpose of the visit and also assisted with the tour of the facility. Administrator Michael Garcia arrived shortly after. The investigation consisted of observation, interviews and a review of pertinent documentation.

Allegation: Facility has a cockroach infestation.
LPA conducted a tour of the physical plant. LPA observed the juice dispenser which was found to be clean and free of pests. The machine was last serviced on 5/27/21. At 10:38am LPA observed in the kitchen a roach motel, and two bait traps, as well as a live roach crawling around the bait trap located underneath the shelf by the kitchen sink. LPA also observed a dead cockroach against the wall in bedroom number 108.

*Continued on 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021

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

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
07/15/2021 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210715124753

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:	07/16/2021
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Administrator Michael Garcia		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff do not properly maintain the facility
Staff are mishandling residents personal funds

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javina George arrived unannounced at the facility to commence an investigation and deliver findings for the allegation(s) listed above. LPA was greeted and granted entry by Director of Nutrition Services Maria Molina and explained the purpose of the visit and also assisted with the tour of the facility. Administrator Michael Garcia arrived shortly after. The investigation consisted of observation, interviews and a review of pertinent documentation.

Allegation: Staff do not properly maintain the facility.
LPA conducted a tour of the physical plant, the facility was observed to be clean, odor and clutter free. LPA observed housekeeping cleaning resident bedrooms, as well as washing laundry. The resident's observed were groomed and dressed appropriately, watching TV and listening to music being played on the piano. All staff were observed wearing the appropriate face coverings (surgical masks). LPA observed the staff schedule and activity calendar. Staff were available to assist resident's with their needs.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021

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-20210715124753

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: 07/16/2021

NARRATIVE

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Based on observation and interview's conducted the allegation of the allegation of staff do not properly maintain the facility is UNSUBSTANTIATED.

Allegation: Staff are mishandling residents personal funds.
LPA reviewed resident #2 (R2) and resident #3 (R3) files. R2 is placed at the facility on an assisted living waiver. R2 has access to their funds, as they have their own bank account. R2 refused to answer questions when LPA attempted to interview them. R2 would not confirm that they had their bank card in their possession. LPA reviewed resident's statement for the facility showing the outstanding amount of rent due. The facility has only received rent for the month of May 2021. Administrator did attempt to take R2 to the bank with LPA present, and had stated that they had previously done so in the past to assist with getting their account straightened out, but R2 continuously refuses. LPA reviewed the facility's resident rent roll form, and observed that R2 did pay their rent for May 2021, with cash, LPA reviewed supporting documents such as a receipt confirming that cash deposit was made into the facility's business bank account.

R3 is conserved and a check is sent and the money is deposited, where R3 can make withdrawals with staff. R3's file was also reviewed and receipts revealed that when R3 was taken to 7 eleven on 7/6/21, per their request that, they only purchased what they had initially requested which was a hot dog, a drink and spicy hot dog. The purchase was paid for with $10.00 cash, and not an ATM card this transaction was also noted on resident's record of resident's safeguarded cash resources log. Based on observation, interview and record review the allegation of Staff are mishandling residents personal funds is UNSUBSTANTIATED. A finding that the complaint is UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated at this time.

An exit interview was conducted and a copy of this report was provided to Administrator Michael Garcia.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021

LIC9099 (FAS) - (06/04)

Page: 5 of 5

Control Number 18-AS-20210715124753

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: 07/16/2021

NARRATIVE

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Per Administrator Michael the facility just had the extermination company came out to the facility to treat for cockroaches on Monday 7/12/21. However, per the invoice reviewed the kitchen was not noted as one of the areas serviced. Based on observation and interviews the allegation of Facility has a cockroach infestation 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 and a copy of this report and appeal rights was provided to Administrator Michael Garcia.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 18-AS-20210715124753

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: 07/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/17/2021 Section Cited HSC 1569.256(a)(5)	1 2 3 4 5 6 7	1569.269 Enumerated rights; severability (a) Residents of residential care facilities for the elderly shall have all of the following rights: (5)To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. This requirement is not met as evidenced by: Based on observation, interview and record review the licensee did not ensure safe and healthful accommodations on 2 out of 2 times.	1 2 3 4 5 6 7	The licensee will have the exterminator treat the kitchen, and any other areas as they see fit. Proof is to be submitted to the department by 5pm on the due date indicated.
	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
	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: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 07/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5