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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880801
Report Date: 07/28/2022
Date Signed: 07/28/2022 10:54:32 AM

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
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/12/2022 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220112113915
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
UNANNOUNCEDTIME BEGAN:
09:00 PM
MET WITH:Administrator Michael GarciaTIME COMPLETED:
11:00 PM
ALLEGATION(S):
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Staff do not properly report incidents involving residents.

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit 07/28/2022 at 09:00 AM to deliver the findings for the above allegations. LPA Brown was greeted and granted entrance to the facility by staff Andrew Castaneda. Administrator Michael Garcia was contacted and arrived during the visit. LPA Brown explained the purpose of today's visit.

The investigation consisted of file review, observation and interviews with relevant parties. LPA Brown toured the facility, conducted interviews and reviewed facility files. The allegation indicates staff do not properly report incidents involving residents. LPA Brown conducted interviews with residents, staffs, resident responsible party. Staffs and responsible party interviews indicated that staff do not properly report incidents involving residents and LPA Brown was able to corroborate the allegation. LPA Brown will be issuing a deficiency as Licensee did not report the incident to R1's responsible party and this poses potential Health, Safety and Personal Rights risk to residents in care.
*** Continuation on LIC9099C ***
Substantiated
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 5
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
01/12/2022 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220112113915

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
UNANNOUNCEDTIME BEGAN:
09:00 PM
MET WITH:Administrator Michael GarciaTIME COMPLETED:
11:00 PM
ALLEGATION(S):
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9
Staff interfering with on going investigations .
Staff unlawfully evicted residents while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit 07/28/2022 at 09:00 AM to deliver the findings for the above allegations. LPA Brown was greeted and granted entrance to the facility by staff Andrew Castaneda. Administrator Michael Garcia was contacted and arrived during the visit. LPA Brown explained the purpose of today's visit.

The investigation consisted of file review, observation and interviews with relevant parties. LPA Brown toured the facility, conducted interviews and reviewed facility files. The first allegation indicates Staff interfering with on going investigations. LPA Brown conducted interviews with residents, staffs, resident responsible party. LPA Brown was not able to obtain evidence to corroborate the allegation. Staffs and responsible party interviews indicated that staff did not interfere with ongoing investigations. Interviews with Resident 3 (R3) responsible party indicated that they initiated and requested the facility to bring R3 to Loma Linda Hospital to be seen by a Specialist. Interview with Staff 1 (S1) indicated that it was R3's family that wanted to bring R3 to Loma LInda Hospital for Specialist Consultation. *** 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: 2 of 5
Control Number 18-AS-20220112113915
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: 07/28/2022
NARRATIVE
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The second allegation indicates that Staff unlawfully evicted residents while in care. During the investigation, LPA Brown was not able to obtain evidence to corroborate the allegation. Interviews with staff and residents indicated that staff did not unlawfully evicted residents while in care. Interviews with staff and R3's responsible party indicated that R3 was transported by Staff 5 to Loma Linda Hospital for a Specialist Consultation but not to evict R3. During the visit, LPA Brown observed R3 still residing at the facility.

Based on the information obtained and observation, there is not enough evidence to state Staff interfering with on going investigations (allegation #1) and Staff unlawfully evicted residents while in care (allegation #2). Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time.

An exit interview was conducted, and a copy of this report (LIC 9099) 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: 3 of 5
Control Number 18-AS-20220112113915
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: 07/28/2022
NARRATIVE
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Based on the information and interviews gathered the allegation Staff do not properly report incidents involving residents 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. Please see
LIC 9099D for deficiencies cited.

An exit interview was conducted where this report (LIC 9099), LIC9099D and Appeal Rights were discussed, and a copy was provided to Administrator Michael Garcia at the conclusion of the visit.
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 5
Control Number 18-AS-20220112113915
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: 07/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/04/2022
Section Cited
CCR
87705(b)(1)
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87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (1) Procedures for notifying the resident's physician, family members ...
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Licensee stated to train staff on CCR 87705(b)(1) and submit Training Log to LPA Brown by POC due date.

Licensee stated to submit Statement of Understanding on CCR 87705(b)(1) to LPA Brown by POC due date.
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Based on observation, interview and record review, the Licensee did not comply with the section cited above by not notifying Resident 1 (R1) responsible party of the incident last 01/09/2022 which poses a potential Health, Safety or 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
LIC9099 (FAS) - (06/04)
Page: 5 of 5