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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880801
Report Date: 08/09/2022
Date Signed: 08/09/2022 02:00:51 PM


Document Has Been Signed on 08/09/2022 02:00 PM - 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:
08/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Michael GarciaTIME COMPLETED:
02:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic.

LPA Gardner met with Administrator Michael Garcia and was granted entry to the facility. At the time of visit there were twelve (12) staff, and seventy-five (75) residents present.

LPA Gardner toured the facility inside and out and went over COVID-19 best practices for infection control and prevention with Michael Garcia. The facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolating/quarantining residents and properly caring for residents with COVID-19 positive results and/or exposures. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, cleaning and disinfection provisions are in adequate quantities, and that staff are trained in the proper use and disposal of PPE. The entrance of the facility has a check in process for visitors that includes a vaccination verification/negative COVID test check, a temperature check, and a symptom check. The residents have hand sanitizer available to them throughout the facility, and the bathrooms were stocked with hand soap and paper towels. The facility has postings throughout the facility for proper cough etiquette, proper hand washing procedure, and/or social distancing guidelines. LPA Gardner requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located in the storage closet. The facility has a thirty (30) day supply of PPE Items such as gloves, face shields, gowns, surgical masks, disinfectant, and hand sanitizer. The facility was notified they need to obtain a full thirty (30) day supply of N95 masks. The facility will be issued a Technical Advisory note for not having a full thirty (30) day supply of N95 masks

All residents and staff are practicing all other COVID-19 precautions, which minimize the risk of them contracting COVID-19.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
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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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
VISIT DATE: 08/09/2022
NARRATIVE
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During today’s visit, LPA Gardner found that a Staff (S1) has been working at the facility for four (4) months without a criminal record clearance. The facility will be issued a citation and issued a $500-dollar civil penalty for allowing S1 to work at the facility without a criminal record clearance.

LPA Gardner also found expired peanut butter, expired soup base chicken, and expired sauerkraut in the kitchen pantry. The facility will be issued a citation for having expired food in the pantry.

Based on the observations made during today’s visit, two (2) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Administrator Michael Garcia, along with a copies of the two (2) LIC-809D forms, LIC-421BG form, LIC-811 form, LIC-9102 form, and a copy of the appeal rights.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/09/2022 02:00 PM - 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: 08/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(9)
87555.General Food Service Requirements. (b)The following food service requirements shall apply:
(9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by having expired dry food in the kitchen panty. LPA found expired peanut butter, expired soup base chicken, and expired sauerkraut in the kitchen pantry which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2022
Plan of Correction
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The licensee has agreed to read regulation 87555 entirely and send LPA self-certify letter that the regulation was read and understood. The license has agreed to train kitchen staff on how to check for expired food. The licensee has agreed to send LPA signed and dated confirmation that each kitchen staff has been trained in food safety.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 08/09/2022 02:00 PM - 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: 08/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)
87355.Criminal Record Clearance. (e)All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above by allowing S1 to work at the facility for four (4) months without a criminal background clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/10/2022
Plan of Correction
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The licensee has agreed to read regulation 87355 entirely and send LPA self-certify letter that the regulation was read and understood. The license has agreed to remove S1 from the facility and not allow S1 to work at the facility until S1 has a criminal background clearance.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4