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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880801
Report Date: 06/14/2021
Date Signed: 06/14/2021 03:31:37 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
02/19/2021 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210219102955
FACILITY NAME:JASMIN TERRACE AT YUCCA VALLEYFACILITY NUMBER:
361880801
ADMINISTRATOR:MICHAEL GARCIAFACILITY TYPE:
740
ADDRESS:55425 SANTA FE TRAILTELEPHONE:
(760) 365-0887
CITY:YUCCA VALLEYSTATE: CAZIP CODE:
92284
CAPACITY:85CENSUS: 63DATE:
06/14/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Michael GarciaTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Facility has bed bugs.

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 bed bugs.
On 2/23/21 LPA conducted a virtual case management visit and observed a bed bug inside of the dryer as well as sitting on the shirt (shoulder) of a resident. Therefore the allegation of facility has bed bugs 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.
*Continued on 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (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
Control Number 18-AS-20210219102955
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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An exit interview was conducted and a copy of this report, 9099D and appeal rights were provided to Administrator Michael Garcia.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (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)
Page: 2 of 4
Control Number 18-AS-20210219102955
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 A
06/15/2021
Section Cited
HSC
1569.269(a)(5)
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1569.269(a)(5) 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.

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.
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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.
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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 EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (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
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
02/19/2021 and conducted by Evaluator Javina George
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210219102955

FACILITY NAME:JASMIN TERRACE AT YUCCA VALLEYFACILITY NUMBER:
361880801
ADMINISTRATOR:MICHAEL GARCIAFACILITY TYPE:
740
ADDRESS:55425 SANTA FE TRAILTELEPHONE:
(760) 365-0887
CITY:YUCCA VALLEYSTATE: CAZIP CODE:
92284
CAPACITY:85CENSUS: 63DATE:
06/14/2021
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Michael GarciaTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff do not provide adequate food service to residents.
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: Staff do not provide adequate food service to residents.
LPA conducted interviews was unable to corroborate the allegation. The feedback provided was that sometimes the food is not what they(resident's) would like to eat, and want to have take out or fast food instead. LPA observed the lunch meal being served to be fresh and have good portion size. Therefore the allegation of Staff do not provide adequate food service to residents 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.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Javina GeorgeTELEPHONE: (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: 4 of 4