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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880801
Report Date: 01/12/2023
Date Signed: 01/12/2023 02:33:52 PM

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
01/20/2022 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220120084124
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: 72DATE:
01/12/2023
ANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Licensee Virginia Garcia/Administrator Michael GarciaTIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff neglect resulted in R1 being injured by R2.
INVESTIGATION FINDINGS:
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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 deliver findings for the allegations listed above. LPA Brown explained the purpose of the requested Office Visit.

The Department investigation included staff interviews, interviews with other pertinent individuals, and review of relevant records. Based on the evidence collected during the investigation, the Department determined that there was corroborating evidence to support that staff neglect resulted in R1 being injured by R2. Department investigation revealed that on 01/09/2022, two (2) staff were working at the facility during the night shift (11:00 PM - 7:00 AM). At around 01:00 AM, Staff # 1 (S1) was on a break when Staff #2 (S2) who was responsible for care and supervision of around 59 facility residents, exited the facility Memory Care Unit to assist another resident.
**** Continuation in 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: 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 18-AS-20220120084124
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: 01/12/2023
NARRATIVE
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Approximately 20 minutes later, S2 returned to the Memory Care Unit and heard R1 yelling from bedroom. S2 went to the room and observed R2 hitting R1 with a medical walking boot. S2 took the boot away from R2 and told R2 to leave the room. During S2 time away from the Memory Care Unit, there was no staff to provide care and supervision to residents in the unit.

Law enforcement and medical assistance was called for R1. According to medical records, R1 sustained a fractured nasal bone and one (1) cm laceration on the right side of forehead.

According to facility records and staff interviews, R2 was known to exhibit aggressive behaviors at times. This was known to occur when R2 is being administered medication or during incontinent care. According to staff, R2 would push, hit and punch staff.

On same day of incident on January 9, 2022, staff reported that R2 was in another resident room grabbing a resident and pushing resident against the wall. On or around 06/03/2020, R2 was reported to have choked another resident. Staff did not report if injuries resulted in either of these cases. In addition, R2 was reported to have been confused and aggressive on 12/14/2019 and 12/15/2019, and staff reported on 11/10/2019 that R2 made threatening statement to harm those at the facility.

Following staff knowledge of R2 behaviors, there was no evidence to support that there was a reappraisal conducted for R2 nor that adequate supervision or assistance was provided to R2. The Department has determined that this neglect resulted in R1 being injured by R2. Complaint allegation is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met. This posed an immediate Health, Safety and Personal Rights risk to residents in care. An immediate Civil Penalty of $500.00 is being assessed. Licensee Garcia and Administrator Garcia were informed that a civil penalty may be assessed based on Health and Safety Code 1569.49 (c)(1). Please see LIC 9099D for deficiencies cited.

An exit interview was conducted where this report (LIC 9099), LIC9099D, LIC421IM and Appeal Rights were discussed, and a copy was provided to Licensee Virginia Garcia and 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: 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
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 18-AS-20220120084124
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: 01/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/13/2023
Section Cited
CCR
87468.1(a)(3)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the...(3) To be free from punishment, humiliation, intimidation, abuse...This requirement is not met as evidenced by:
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Licensee stated to train all staff on CCR 87468.1(a)(3) and submit proof of Training Log to LPA Brown by POC due date.
Licensee stated to submit signed Statement of Understanding on CCR 87468.1(a)(3) and submit to LPA Brown by POC due date.
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Based on interview and records review, the Licensee did not comply with the section cited above due to facility staff neglect to ensure R1 is free from abuse from R2 and resulted to R1’s injury 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
LIC9099 (FAS) - (06/04)
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