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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880801
Report Date: 01/09/2023
Date Signed: 01/10/2023 08:30:06 AM


Document Has Been Signed on 01/10/2023 08:30 AM - 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:
01/09/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:Michael Garcia, Administrator TIME COMPLETED:
03:05 PM
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On 01/09/2023, at 9:28 a.m., Licensing Program Analysts (LPA’s) Rayshaun Nickolas and Magda Malcore made an unannounced visit to the facility to conduct a Health and Safety case management visit. LPAs met with Administrator Michael Garcia and explained the purpose of the visit.

During today's case management visits LPAs conducted a tour of the facility inside and out to assess for any Health and Safety concerns of the clients in care. At 9:36 a.m., LPAs met with Dietary Supervisor Maria Molina and toured the kitchen. LPAs observed that the kitchen was clean. LPAs also inspected facility food supplies and observed more than two (2) days supply of perishable foods and more than seven (7) days supply of non-perishable foods. LPAs also observed expiration dates on the food supply. LPAs also obtained copies of the food delivery invoices.

LPAs also obtained copies of service invoices from Western Exterminator Company for the months of September, October, November, and December of 2022, which documents interior and exterior treatment services. Per the Administrator the facility does not use an outside exterminator to treat bedbugs; however, the facility treats bed bugs by the use of a heat treatment machine that was purchased by the corporate office.

LPAs randomly selected nine (9) clients from the facility's client roster and conducted a medication audit. LPAs observed that although medication were listed on the Central Stored Medication and Destruction Record (LIC 622), any subsequent refill for that medication was not referenced on the LIC 622, the refill of said medication changed the RX number referenced on the medication. LPAs also discovered during their medication audit that the Medication Administration Records (MARs) for January 2023 was not thoroughly filled out on all nine (9) clients. LPAs discussed this issue with the med techs, who stated that they were working on updating the LIC 622 and the MARs.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to the administrator.


SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2023
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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