361880801-2-17-2023-56-AS-KCLS-CQNPBU-20230407111055

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880801
Report Date: 02/17/2023
Date Signed: 02/17/2023 01:35:13 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/16/2023 and conducted by Evaluator Magda Malcore

COMPLAINT CONTROL NUMBER: 56-AS-20230216082711

FACILITY NAME:	JASMIN TERRACE AT YUCCA VALLEY		FACILITY NUMBER:	361880801
ADMINISTRATOR:	MICHAEL GARCIA		FACILITY TYPE:	740
ADDRESS:	55425 SANTA FE TRAIL		TELEPHONE:	(760) 365-0887
CITY:	YUCCA VALLEY	STATE: CA	ZIP CODE:	92284
CAPACITY:	85	CENSUS: 70	DATE:	02/17/2023
		UNANNOUNCED	TIME BEGAN:	09:48 AM
MET WITH:	Michael Garcia, Administrator		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Resident had multiple falls due to lack of supervision
Staff member physically abused resident causing injury

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs), Magda Malcore and Anna Bueno conducted an unannounced visit to initiate and deliver a complaint investigation regarding the above-mentioned allegations. LPAs met with Administrator, Michael Garcia and informed Garcia the purpose of the visit. During today’s visit, LPAs toured the facility, obtained copies of relevant documents, interviewed staff and residents.

Records reveal that resident does not require walking assisted devices. LPAs observed resident (R1) walking on their own. Interview with staff reveal that R1 does not require assistance getting out of bed. LPAs reviewed video of incident that occurred on 2/12/23 involving R1. The video showed R1 walking and tripping on a long blanket that R1 was holding and fell face down on the floor.

LPAs attempted to interview R1 but they were not responsive. Resident interviews deny that staff is physically abusive. Resident interviews confirm that they have not heard of staff abusing residents.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 56-AS-20230216082711

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: JASMIN TERRACE AT YUCCA VALLEY	FACILITY NUMBER: 361880801
	VISIT DATE: 02/17/2023

NARRATIVE

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Based on documents reviewed and interviews there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Unsubstantiated meaning that 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.

An exit interview was conducted with Administrator, Michael Garcia and a copy of this report (LIC 9099) was provided to Garcia at the conclusion of the visit.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023

LIC9099 (FAS) - (06/04)

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