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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880801
Report Date: 08/01/2022
Date Signed: 08/01/2022 09:51:11 AM


Document Has Been Signed on 08/01/2022 09:51 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: 73DATE:
08/01/2022
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator Michael GarciaTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Melody Brown arrived at the facility 08/01/2022 at 09:15 AM announced in order to amend the LIC809D Case Magement - Deficiency issued last 07/28/2022 . LPA Brown met with Administrator Michael Garcia and LPA Brown explained the purpose of today's visit.

An exit interview was conducted where this report (LIC809) was 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: 08/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/01/2022
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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