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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880801
Report Date: 01/26/2023
Date Signed: 01/26/2023 01:41:09 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
01/20/2023 and conducted by Evaluator Bernadette Allen
COMPLAINT CONTROL NUMBER: 56-AS-20230120164232
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: 70DATE:
01/26/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Michael Garcia Administrator TIME COMPLETED:
01:55 PM
ALLEGATION(S):
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Staff did not prevent roaches in the facility
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Bernadette Allen arrived at the facility unannounced to conduct a complaint investigation and deliver the findings for the allegations listed above. LPA met with Administrator Michael Garcia.

During LPA Allen visit a tour of the facity was done and there were roaches seen through out the facility. Documents were also reviewed and the exterminators have provided recommendations for the inside and outside of the facility to assist with the control and or ellimination of the rodents. The records reviewed does show that there were visits on 12/30/2022, 1/9/2023 and 1/25/2023 and the recommendations have not been put in place control and /or eliminate the rodent problem.

Based on observation,record review and interviews conducted the above allegation is Substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
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 56-AS-20230120164232
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: 01/26/2023
NARRATIVE
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 A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. A deficiency is being cited on the attached LIC 9099-D.

An exit interview where this report was discussed with Michael Garcia and a copy of this report was provided with appeal rights at the conclusion of the visit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20230120164232
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: 01/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/27/2023
Section Cited
CCR
87303(a)(c)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety... This requirement was not met as evidenced by:
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Licensee will repair holes/gaps in walls throughout the facility as recommended by the exterminator company this includes kitchen,dining area. The outside west wing of the facility need to be cleaned and the screen needs to be placed on door/pannels on outside/inside of air conditioners. Proof of correction will be submittedd to LPA Allen by the plan of correction date of 1/27/2023 by pictures.
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Based on observation, interview and record review, the Licensee did not comply with the section cited above by not applying the recommendation of the exterminator for the rodents/roaches at the facility which poses immediate health, safety and personal rights risks to residents in care.

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The licensee with also provide a signed written statement confirming that they have read the regulation cited to its entirety and confiming understanding. The written statement must signed and emailed by 1/27/2023.
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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: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3