361880801-8-2-2021-18-AS-JESL-CFWRWZ-20220701132359

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880801
Report Date: 08/02/2021
Date Signed: 08/02/2021 11:49:26 AM

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
07/21/2021 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210721135526

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: 62	DATE:	08/02/2021
		UNANNOUNCED	TIME BEGAN:	09:33 AM
MET WITH:	Maria Molina-Director of Nutrition Services		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Administrator is not present on the premises as required.
Staff did not administer a resident's medication as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javina George made an unannounced visit to commence a complaint investigation as well as to deliver findings for the allegation(s) listed above. LPA met with Maria Molina-Director of Nutrition Services and explained the purpose of the visit. Administrator was unavailable due to being out and picking up a new resident for the facility. The investigation consisted of a review of Medical Authorization Records (MAR), medications, file review, interviews with staff and residents as well as observation.

Allegation: Administrator is not present on the premises as required.
LPA George had a discussion with Administrator prior to the complaint, regarding his availability. The most recent conversation occurred on 6/14/21. LPA and Administrator discussed, Administrator putting himself on the facility schedule and indicating the hours that he will be working on the floor, so that there would not be a question as to when he would be working. Administrator stated that he could do that, as it is hard to separate the times, with him residing on grounds. During 6/14/21,L PA also observed a resident pacing back and forth in front of Administrator’s office whom made the statement multiple times “I never know when you are going to be here”.

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: 08/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2021

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 3

Control Number 18-AS-20210721135526

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: 08/02/2021

NARRATIVE

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LPA has been contacted by an individual from a different agency, on 7/28/21 stating that they were having a difficult time getting a hold of the administrator and wanted to confirm contact information. During an interview with Administrator he stated that he was on vacation for two weeks and the facility designee is Maria Molina-Director of Nutrition Services, whom is also indicated on the LIC308. LPA conducted interviews and the consensus was that it is unknown when the administrator would be on the premises. Per Administrator he is always available due to being on-call 24/7. LPA has called the facility and staff has informed LPA that administrator was not available and did not know when he would be. LPA reviewed the facility schedule and there were no hours indicating as to when the Administrator would be available, as he was not listed. Therefore, the allegation of Administrator is not present on the premises is SUBSTANTIATED.

Allegation: Staff did not administer a resident’s medication as prescribed.
LPA George reviewed MARs, as well as the prescribed medications, which revealed that Resident # 1(R1) was in fact not given their medications prescribed. R1 was admitted to the facility on 06/02/21 and was prescribed the following: Clonazepam, Ziprasidone, Halperidol, Benztropine, Trazadone). LPA interviewed R1 whom was not able to confirm that they had been without their medications. However, it was confirmed during staff interviews that at the time of admission R1 only had 2 weeks worth of their prescribed medications, and that at minimum of 1 month, that R1 was without their prescribed medication. Per staff interviews staff made attempts but the Doctor stated that they had not seen R1 since 2019, but the prescription label revealed that R1 was prescribed medication in March 2020. Per facility staff a second request was made and did not hear back from the Doctor. There was not any recent follow up until 7/28/21, which is when R1 was able to get their prescription filled. LPA observed at the time of the visit that R1 does have a 30 day supply of medication. Therefore, the allegation of Staff did not administer a resident’s medication as prescribed 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 appeal rights was provided to Maria Molina-Director of Nutrition Services.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 18-AS-20210721135526

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: 08/02/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/03/2021 Section Cited CCR 87564(a)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: based on observation, interview and record review the licensee did not administrator medication as prescribed on 1 out of 1 times. This poses an immediate health, safety or personal rights risk to persons in care.	1 2 3 4 5 6 7	The administrator agrees to have a medication administration training, focusing on the importance of taking prescribed medication. Proof is to be submitted to the department by 5pm on the due date indicated.
Type B 08/16/2021 Section Cited HSC 1569.618(a)	1 2 3 4 5 6 7	1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling (a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. This requirement is not met as evidenced by: based on observation, interview and record review the administrator was not available during normal working hours on 1 out of 1 times. This poses a potential health, safety or personal rights risk to persons in care.	1 2 3 4 5 6 7	The administrator agrees to add himself to the schedule indicating the hours and days that he will be working at the facility and follow it. Administrator will send a revised copy of the schedule for the month of August. Proof is to be submitted to the department by 5pm on the due date indicated.
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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 Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina George	TELEPHONE: (951) 204-7107
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3