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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880801
Report Date: 01/12/2023
Date Signed: 01/12/2023 02:38:12 PM


Document Has Been Signed on 01/12/2023 02:38 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: 74DATE:
01/12/2023
TYPE OF VISIT:Case Management - DeficienciesANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Licensee Virginia Garcia and Administrator Michael GarciaTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Melody Brown met with Licensee Virginia Garcia and Administrator Michael Garcia at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 01/12/2023 at 01:00 PM to initiate a Case Management Office Visit. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of interviews and a review of pertinent documentation.

On 12/29/2022, LPA Brown received Personnel Report Summary (LIC500) from Administrator Garcia and Staff December 2022 Work Schedule. LPA Brown observed per records review that Staff # 5 (S5) was listed “pending” in LIC500 with date 12/05/2022 but per 12/2022 Staff Schedule received, it indicated S5 working at the facility 12/01/2022. On 01/09/2023, LPA Brown received 12/2022 and 01/2023 Staff Work Schedule from Administrator Garcia and both 12/2022 and 01/2023 staff work schedule indicated S5 working at the facility. On 01/12/2023, LPA Brown contacted S5 and S5 reported working at the facility since 06/07/2021 on a night (NOC) shift schedule. During the office visit on 01/12/2023, Administrator Garcia confirmed that S5 started working at the facility 06/07/2021. LPA Brown observed per records review that S5 criminal background clearance is “in process” per Guardian website and the facility allowed S5 to work at the facility without criminal background clearance. LPA Brown will issue a deficiency as this pose immediate health, safety and personal rights risk to residents in care.

LPA Brown reviewed compliance history and observed that the facility was issued the same deficiency for a staff working at facility without criminal background clearance last 08/09/2022. Civil Penalty was assessed for repeat violation on Criminal Background Clearance within a 12-month period with the amount of $3,000.00 and will continue to be assessed of $100.00 per day per citation until corrected during the Office Visit due to the facility allowed S5 to work without Criminal Background Clearance since 06/07/2021.

An exit interview was conducted with Licensee Virginia Garcia and Administrator Michael Garcia where a copy of this report (LIC 809) along with LIC 809D, LIC421BG 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: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/12/2023 02:38 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: 01/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/13/2023
Section Cited

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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...(1) Obtain a California clearance... This requirement is not met as evidenced by:

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Licensee stated to submit Signed Statement of Understanding on CCR 87355(e)(1) to LPA Brown by POC due date.
The licensee stated to remove S5 from the facility and not allow S5 to work at the facility until S5 has a criminal background clearance.
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Based on interview and records review, the Licensee did not comply with the section cited above by allowing Staff #5 to work at the facility without criminal background clearance since 06/07/2021 which pose immediate health, safety and 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: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023
LIC809 (FAS) - (06/04)
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