361880801-1-18-2022-18-AS-EMAN-CFVUCZ-20220630152845

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880801
Report Date: 01/18/2022
Date Signed: 01/18/2022 04:18:19 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
01/11/2022 and conducted by Evaluator Rohit Lama

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220111153446

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: 58	DATE:	01/18/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Michael Garcia, Administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Lack of supervision resulting in resident wandering away from facility

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Melody Brown and Rohit Lama made an unannounced joint visit to the facility for the purpose of investigating the allegation(s) of this complaint. LPAs identified themselves and the purpose of the visit to Administrator Michael Garcia, who arrived to the facility during the inspection. Below is a summary of what LPAs Brown and Lama observed:

The investigation was conducted by LPAs Brown and Lama. LPAs toured the facility, conducted interviews, and reviewed facility files. The allegation indicates that due to a lack of supervision on 1/8/2022 Resident 1 (R1) wandered away from the facility.

LPAs were informed that on the night of 1/8/2022, R1 managed to leave the facility via the delayed egress door in the hallway and supposedly made it to the curb where she fell and obtained minor injuries to R1’s face.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Rohit Lama	TELEPHONE: (951) 217-9826
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022

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 3

Control Number 18-AS-20220111153446

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: 01/18/2022

NARRATIVE

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Interviews with S1, S2, S3 indicate that R1’s absence was not known until a call was received from the two individuals (names not obtained) that had found her. This poses an immediate health & safety risk to the resident in care. LPAs also checked the delayed egress door’s alarm and observed that it goes off the moment the door handle bar is depressed and remains activated until a code is entered. LPAs also observed that the delayed egress door only opens after the handle bar is depressed for a duration of one minute. LPAs attempted to interview Resident 1 (R1) however were unable to due to the fact that R1 is not alert nor oriented.

Based on resident and staff interviews and record reviews, LPAs determined that the allegation: Lack of supervision resulting in resident wandering away from facility, 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 Micahel Garcia where a copy of this report (LIC 9099) along with LIC 9099-D and Appeal Rights were reviewed and a copy was provided.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Rohit Lama	TELEPHONE: (951) 217-9826
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20220111153446

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: 01/18/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/25/2022 Section Cited CCR 87705(k)(8)	1 2 3 4 5 6 7	87705 - Care of Persons with Dementia - Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents and to escort residents who leave the facility. This requirement was not met as...	1 2 3 4 5 6 7	Licensee needs to hire additional care giviers and schedule additional staff per shift to adequately meet the needs of the residents in care. Licensee shall provide proof of hiring attempts by POC due date.
	8 9 10 11 12 13 14	evidenced by: Interviews, record reviews, and observation, the licensee did not ensuire that staff were able to provide adequate care and supervision for R1. R1 was found wandering outside the facility on 1/9/2022 without care and supervision. Interviews revealed that only two staff members were working that shift. This poses an immediate health & safety risk to the residents 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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Rohit Lama	TELEPHONE: (951) 217-9826
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022

LIC9099 (FAS) - (06/04)

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