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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880801
Report Date: 08/26/2022
Date Signed: 08/26/2022 11:04:32 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
01/28/2022 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220128162918
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: 77DATE:
08/26/2022
ANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Michael GarciaTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Facility does not provide activities
INVESTIGATION FINDINGS:
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On 08/26/2022 at 10:30 AM, Licensing Program Analysts (LPA) Melody Brown and Paola Guerrero met with Administrator Michael Garcia at California Community Care Licensing Division (CCLD) Regional Office to deliver the findings for the above allegation.

The investigation was conducted by LPA Brown. LPA Brown toured the facility, conducted interviews, and reviewed facility files. The allegation indicates that facility does not provide activities. Interviews with staffs and residents indicated that the facility has no activities for residents. LPA Brown interviewed six (6) residents and seven (7) staffs. Interview with residents indicated that facility do not have activities for the residents and LPA Brown was not able to interview three (3) residents due to them being not oriented and unable to answer LPA Browns' questions. LPA Brown interviewed seven (7) staff. and five (5) out of seven (7) staff stated that the facility do not have activities for residents.

*** continuation on LIC 9099C***
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: 08/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 18-AS-20220128162918
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: 08/26/2022
NARRATIVE
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Based on residents and staffs interviews and record reviews, LPAs Brown and Guerrero determined that the allegation Facility does not provide activities 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.

LPA Brown reviewed compliance history and observed that the facility was issued the same deficiency for not providing activities to residents last 02/25/2022. Civil Penalty was assessed for repeat violation within a 12-month period in the amount of $250.00 per citation and will continue to be assessed of $100.00 per day per citation until corrected.

An exit interview was conducted with Administrator Garcia where a copy of this report (LIC 9099) along with LIC 9099-D, LIC421FC and Appeal Rights were discussed and provided.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20220128162918
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: 08/26/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/01/2022
Section Cited
CCR
87705(c)(7)
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87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia ... (7) An activity program shall address the needs and limitations of residents with ... This requirement is not met as evidenced by:
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Licensee will submit List of Activities and Activities Schedule for residents in care self-certified by the Activities Director and Administrator by POC due date to Community Care Licensing Department (CCLD) or LPA Brown.
Licensee will submit Statement of Understanding for CCR 87705(c)(7) to LPA Brown by POC due date.
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Based on observations, interviews and record review, the licensee did not provide activities for residents at the facility, which poses a potential Health, Safety, or Personal rights risk to persons 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: 08/26/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC9099 (FAS) - (06/04)
Page: 3 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
01/28/2022 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220128162918

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: 77DATE:
08/26/2022
ANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Michael GarciaTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Resident sustained bruises while in care
Facility does not meet resident's nutritional needs
INVESTIGATION FINDINGS:
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On 08/26/2022 at 10:30 AM, Licensing Program Analysts (LPA) Melody Brown and Paola Guerrero met with Administrator Michael Garcia at California Community Care Licensing Division (CCLD) Regional Office to deliver the findings for the above allegations.

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 Resident sustained bruises while in care. LPA Brown conducted interviews with residents, staffs, and witness. LPA Brown was not able to obtain evidence to corroborate the allegation. Interview with Resident 1 (R1) private caregiver indicated that bruise was observed at R1, however Staffs’ interviews indicated that no residents sustained bruises while in care.

*** 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: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20220128162918
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: 08/26/2022
NARRATIVE
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Moreover, staff interviews also indicated that no bruise was observed at R1 when they conducted physical assessment/check on R1. Interviews with residents revealed no resident sustained bruises while in care.

The second allegation indicates Facility does not meet resident's nutritional needs. During the investigation, LPA Brown was not able to obtain evidence to corroborate the allegation. Interviews with staff and residents indicated that Facility meets resident's nutritional needs and breakfast, lunch, dinner and snacks were provided to all residents. Also, residents, staffs and witness interviews indicated sufficient amount of food were served to all residents and all residents can request for additional servings if they prefer. In addition, interviews with staffs revealed that they all check on their residents after meal to make sure that all residents eat their meals.

Based on the information obtained and observation, there is not enough evidence to state Resident sustained bruises while in care (allegation #1) and Facility does not meet resident's nutritional needs (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: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5