361880801-6-15-2021-18-AS-JESL-CFWRZS-20220701132827

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880801
Report Date: 06/14/2021
Date Signed: 06/15/2021 10:57:25 AM

Unsubstantiated

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
06/09/2021 and conducted by Evaluator Javina George

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210609125647

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: 63	DATE:	06/14/2021
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Administrator Michael Garcia		TIME COMPLETED:	12:01 PM

ALLEGATION(S):

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Staff did not ensure resident is fed.
Resident's diapering needs are not being met.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to commence a complaint investigation and to deliver findings for the allegation(s) listed above. LPA was greeted by Dietary Services Director Maria Molina. Administrator arrived at the facility a few hours after LPA's arrival. The investigation consisted of a review of pertinent documentation and interviews.

Allegation: Staff did not ensure resident is fed.
LPA conducted interviews and reviewed R1 physician's report and resident appraisal. The feedback provided is that R1 is to be spoon-fed. The facility has a total of 4 designated Caregivers (2 Monday-Friday and 2 on the weekends) that have been assigned to feed R1 their meals. Dietary Services Director Maria and Hospice Nurse confirmed that the directive was given to increase R1's portion to two for each meal about three weeks ago. Per Maria there was an isolated incident that occurred recently where a plate was left still covered in saran wrap, as R1 was full. Hospice Nurse shared that R1 does eat very well and typically does not like to eat a double portion for breakfast, if R1 does it would either be for lunch and or dinner.

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: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

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 4

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
06/09/2021 and conducted by Evaluator Javina George

COMPLAINT CONTROL NUMBER: 18-AS-20210609125647

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: 63	DATE:	06/14/2021
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:			TIME COMPLETED:	12:01 PM

ALLEGATION(S):

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Facility has pests.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javina George made an unannounced visit to the facility to commence a complaint investigation and to deliver findings for the allegation listed above. LPA was greeted by Dietary Services Director Maria Molina. Administrator arrived at the facility a few hours after LPA's arrival. The investigation consisted of a review of pertinent documentation, observation and interviews.

Allegation: Facility has pests.
LPA conducted reviewed documentation and interviews. LPA was able to corroborate the allegation; feedback provided was that there were cockroaches observed mostly in bathrooms in resident rooms and around the sink and at the bottom of the toilet, as recent as May 2021. Administrator Michael Garcia stated that the facility continued to work with the extermination company. Based on interviews and record review the allegation of Facility has pests 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. A copy of this report, 9099D and appeal rights was discussed and provided to Administrator Michael Garcia.

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: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 18-AS-20210609125647

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: 06/14/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/28/2021 Section Cited HSC 1569.256(a)(5)	1 2 3 4 5 6 7	1569.269 ENUMERATED RIGHTS: SEVERABILITY Residents of residential care facilities for the elderly shall have all of the following rights: To be accorded safe, healthful, and comfortable accommodations, furnishings, and equipment. This regulation was not met as evidenced by: The facility has a pest infestation. This is an immediate Health and Safety risk to residents in care. This requirement is not met as evidenced by: Based on observation, interviews and record review the licensee did not ensure that the residents were accorded safe, healthful and comfortable accommodations for multiple residents in care.	1 2 3 4 5 6 7	Licensee is to ensure the exterminator company services all affected resident bedrooms, and other areas that the facility has had complaints and observations of pests in identified areas. Submit the exterminator invoice to department by 5pm on indicated due date.
	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: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 18-AS-20210609125647

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: 06/14/2021

NARRATIVE

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Based on interviews and records review the allegation of Staff did not ensure resident is fed is UNSUBSTANTIATED.

Allegation: Resident's diapering needs are not being met.
LPA reviewed documentation as well as conducted interviews with staff and resident's. The Caregivers stated that any residents with incontinence care is checked every two hours, or as needed. There are also some residents that can vocalize their need to be changed, as well. There are times a resident will walk by and staff observed that the resident needs to be changed. Prior to the end of each shift all resident's are to be to checked before the oncoming shift as well. The allegation of Resident's diapering needs are not being met
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: 06/14/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2021

LIC9099 (FAS) - (06/04)

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