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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880801
Report Date: 07/28/2022
Date Signed: 07/28/2022 10:13:02 AM


Document Has Been Signed on 07/28/2022 10:13 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507



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: 75DATE:
07/28/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Michael GarciaTIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 07/28/2022 at 09:00 AM unannounced in order to initiate a Case Management visit. LPA Brown met with Administrator Michael Garcia and LPA Brown explained the purpose of today's visit.

During the visit last 04/25/2022 at 12:30 PM, LPA Brown pressed the pull button/cord at room number #116 located near the resident bed and LPA Brown observed the call button/pull cord is not working. LPA Brown pressed the pull button/cord at resident bathroom and LPA Brown observed that it works and creates a sound at the reception area to inform staff that resident on that room number needs help. LPA Brown informed Administrator Garcia that the call button near the residents’ bed needs to be fix and Administrator Garcia said "I'll fix that today." Administrator Garcia also added that they assigned two (2) staff and one (1) staff reliever at the Memory Care available to assist the residents. LPA Brown pressed the call button at resident bathroom (room #116) and it took 5 minutes for a staff to arrive to help. LPA Brown will be issuing a citation for the observed pull button/cord not working near the resident bed as this deficiency poses immediate risk to residents in care.

In addition, LPA Brown reviewed facility's incident reports and LPA Brown did not find any Incident Reports that the facility submitted to Community Care Licensing Division (CCLD) to report R1's unwitnessed falls and LPA Brown will issue a citation for not reporting R1's unwitnessed falls at the facility as this pose potential risk to residents in care.

An exit interview was conducted where this report (LIC809), LIC809D and Appeal Rights were discussed and provided to Administrator Michael Garcia.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/28/2022 10:13 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: JASMIN TERRACE AT YUCCA VALLEY
FACILITY NUMBER: 361880801

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/26/2022
Section Cited

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87303 Maintenance and Operation (a) The facility shall be clean, safe and sanitary and in good repair at all times. Maintenance shall include ... This requirement is not met as evidenced by:
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Based on observations and interviews, the Licensee did not comply with the section cited above by having a pull button/cord in room 116 near the resident bed in disrepair which poses an immediate health, safety and personal rights risks to residents in care.
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Also, LIcensee stated to check all residents room that the pull button/cord near resident beds and bathrooms are working and submit proof to LPA Brown by POC due date.
Type B
05/02/2022
Section Cited

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven ...
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Based on observations, interviews and record review, the Licensee did not comply with section cited above by not reporting incidents of unwitnessed fall of Resident 1 (R1) at the facility to Community Care Licensing Division (CCLD) which poses potential health, safety and personal rights risk to resident in care.
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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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 07/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/28/2022
LIC809 (FAS) - (06/04)
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