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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880801
Report Date: 04/25/2022
Date Signed: 07/28/2022 09:51:34 AM

Unsubstantiated


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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/01/2021 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211001092216
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: 65DATE:
04/25/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Michael GarciaTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Insufficient staffing to meet resident's needs.
Staff did not respond to resident's call button in a timely manner.
Resident has sustained several unwitnessed falls due to lack of supervision.
INVESTIGATION FINDINGS:
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2
3
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5
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7
8
9
10
11
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13
Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility 07/28/2022 at 9:00 AM to deliver findings for the above allegations with Administrator Michael Garcia. LPA Brown introduced herself and explained the purpose of today’s visit. The investigation consisted of interviews with pertinent parties and records review.

The first allegation indicates Insufficient staffing to meet residents needs. LPA Brown did not find evidence to corroborate the allegation. Interviews with staffs, residents, witness and documents review did not indicate insufficient staff working at the facility to meet resident's needs. Also, interviews revealed that facility needed more staff but all work shifts were covered by staff working extra hours if needed.

The second allegation indicates Staff did not respond to residents' call button in a timely manner. Based on residents, staffs and witness interviews and observation, LPA Brown did not find evidence to corroboare the allegation. ***Continuation in LIC9099C***
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/01/2021 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211001092216

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: 65DATE:
04/25/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Michael GarciaTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Questionable Death.
Resident's toileting needs are not being met.
Resident's bathing needs are not being met.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility 04/25/2022 at 11:00 AM to deliver findings for the above allegations with Administrator Michael Garcia. LPA Brown introduced herself and explained the purpose of today’s visit. The investigation consisted of interviews with pertinent parties and records review.

The first allegation indicates questionable death of a resident. LPA Brown did not find evidence to corroborate the allegation. Interviews with staff, residents and documents review indicated no questionable death of a resident occurred at the facility. LPA Brown reviewed Death Report submitted to Community Care Licensing Department (CCLD) and reviewed Resident 7 medical records and it indicated R7's natural cause of death and R7 was on hospice.

***Continuation in LIC9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 18-AS-20211001092216
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
, CA 92507
FACILITY NAME: JASMIN TERRACE AT YUCCA VALLEY
FACILITY NUMBER: 361880801
VISIT DATE: 04/25/2022
NARRATIVE
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The second allegation indicates Resident's toileting needs are not being met. LPA Brown did not find evidence to corroborate the allegation. Interviews with staff, residents and documents review indicated residents toileting needs are being met. Interviews with staffs indicated all residents incontinence needs are checked by staff every two (2) hours. Interviews with residents revealed that all staff checks on them and their incontinence needs are met.

The third allegation indicates Resident's bathing needs are not being met. LPA Brown did not find evidence to corroborate the allegation. Interviews with staff, residents and documents review indicated residents toileting needs are being met. Interviews with staffs indicated that they have a Bathing Schedule that they follow to make sure all residents bathing needs are met. Interviews with residents indicated that their bathing needs are met at the facility. Administrator Garcia showed proof of Bathing Log and Bowel Movement Log of a resident during the visit.

Based on interviews and records review, the above allegations Questionable Death (Allegation #1),Resident's toileting needs are not being met.(Allegation #2), and Resident's bathing needs are not being met (Allegation #3) are UNSUBSTANTIATED. A finding of unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.



No deficiencies were cited during this visit.

An exit interview was conducted, and a copy of this report (LIC9099) 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: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 18-AS-20211001092216
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
, CA 92507
FACILITY NAME: JASMIN TERRACE AT YUCCA VALLEY
FACILITY NUMBER: 361880801
VISIT DATE: 04/25/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
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19
20
21
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23
24
25
26
27
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30
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32
 Interviews with staff and residents revealed that it takes about 10 minutes to 15 minutes for a staff to respond to residents when they need assistance by pressing the call/pull cord button.

The third allegation indicates Resident has sustained several unwitnessed falls due to lack of supervision. LPA Brown did not find evidence to corroborate the allegation. Interviews with staff, residents and witness indicated that few unwitnessed falls occured at the facility and staff always helps residents. Also, interviews with staffs, residents and witness indicated that there's no incident that a resident sustained unwitnessed falls due to lack of supervision.

Based on LPA Brown’s observations, interviews, and record review, the above allegations Insufficient staffing to meet resident's needs (Allegation #1), Staff did not respond to resident's call button in a timely manner (Allegation #2), and Resident has sustained several unwitnessed falls due to lack of supervision (Allegation #3) are UNSUBSTANTIATED. A finding of unsubstantiated means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted where this report (LIC9099) 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: 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
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 18-AS-20211001092216
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
, CA 92507

FACILITY NAME: JASMIN TERRACE AT YUCCA VALLEY
FACILITY NUMBER: 361880801
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
04/26/2022
Section Cited
CCR
87705(c)(4)
1
2
3
4
5
6
7
87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to ... This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee stated to have additional staff working on the floor available to assist residents that need help. Licensee will submit Staff Work Schedule that shows adequate number of direct care staff scheduled to work on each shift.

8
9
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Based on observations, interviews and record review, the Licensee do not have adequate number of direct care staff working at the facility to meet residents needs which poses an immediate risk to resident in care.
8
9
10
11
12
13
14
Licensee will submit Statement of Understanding for CCR 87705(c)(4) to LPA Brown by POC due date.
Deficiency Dismissed
Type A
04/26/2022
Section Cited
CCR
87303(a)
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2
3
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5
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7
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include ... This requirement is not met as evidenced by:
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4
5
6
7
Facility agreed to replace and/or repair call button near residents' bed (Room #116) by POC due date and submit proof to LPA Brown by POC due date.
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Based on observations, interviews and record review, the facility do not have working call button (rroom #116) near the residents bed to alert staff if residents need care which poses an immediate risk to resident in care.
8
9
10
11
12
13
14
 Also, Licensee stated to check all residents rooms that the call button near resident beds and bathroom are working and submit proof of correction to LPA Brown by POC due date.
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: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 18-AS-20211001092216
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
, CA 92507

FACILITY NAME: JASMIN TERRACE AT YUCCA VALLEY
FACILITY NUMBER: 361880801
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
04/26/2022
Section Cited
CCR
87705(c)(4)
1
2
3
4
5
6
7
87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to ... This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee stated to train all staff to make sure that they all respond to resident’s call button in a timely manner and will submit Training Log to LPA Brown by POC due date.
8
9
10
11
12
13
14
Based on observations, interviews and record review, the Licensee do not have adequate number of direct care staff working at the facility to respond to resident’s call button in a timely manner in which poses an immediate risk to resident in care.
8
9
10
11
12
13
14
Deficiency Dismissed
Type A
04/26/2022
Section Cited
CCR
87705(c)(4)
1
2
3
4
5
6
7
87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to ... This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee stated to have additional staff to supervise residents and prevent unwitnessed falls. Licensee will submit Staff Work Schedule that shows adequate number of direct care staff scheduled to work on each shift by POC due date to LPA Brown.
8
9
10
11
12
13
14
Based on observations, interviews and record review, the Licensee did not comply by not having adequate number of staff working at the facility to monitor residents and prevent unwitnessed falls which poses an immediate risk to resident in care.
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9
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14
Licensee will have all staff complete a Resident Status Check Log every hour to appropriately supervise all residents and prevent unwitness fall. Licensee will also train all staff on the proper procedure and implementation of the Resident Status Check Log and will submit a copy of Resident Status Check Log and Training Log to LPA Brown by POC due date.
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: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 18-AS-20211001092216
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
, CA 92507

FACILITY NAME: JASMIN TERRACE AT YUCCA VALLEY
FACILITY NUMBER: 361880801
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
05/02/2022
Section Cited
CCR
87705(b)(1)
1
2
3
4
5
6
7
87705 Care of Persons with Dementia
(b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of ...(1) Procedures for notifying the resident’s ... This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee stated to report all incidents at the facility to CCLD and train staff on reporting requirements. Also, Licensee will submit Statement of Understanding for 87705(b)(1)and Staff Training Log to LPA Brown by POC due date.
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14
Based on observations, interviews and record review, the Licensee did not comply by not reporting incidents of unwitnessed fall of Resident 1 (R1) at the facility to Community Care Licensing Department (CCLD) which poses a potential risk to resident in care.
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7
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7
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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: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 04/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/25/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7