361880801-4-3-2023-56-AS-KCLS-CR7UNC-20230424154344

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880801
Report Date: 04/03/2023
Date Signed: 04/03/2023 01:42:14 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
03/09/2023 and conducted by Evaluator Magda Malcore

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230309152937

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: 74	DATE:	04/03/2023
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Michael Garcia, Administrator/Licensee		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff hit resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to deliver findings on the above complaint allegation. LPA met with Licensee/Administrator, Michael Garcia and discussed the purpose of the visit. The investigation consisted of interviews with residents, staff, and document review.

Regarding the allegation that staff hit resident, the Administrator and all staff interviewed deny hitting residents or witnessing staff hitting residents in care. Three (3) out of five (5) residents deny being hit by staff nor have they witnessed staff hit any residents in care. Two (2) residents we unable to corroborate or refute the allegation. Interviews with staff reveal that resident #1 (R1) had an unwitnessed fall that resulted in R1 sustaining a cut above left eye. An unusual incident/injury report was submitted to Community Care Licensing. R1 was given first aid, medically assessed by two (2) caregivers and R1’s family were notified of the incident.

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: 04/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023

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-20230309152937

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: 04/03/2023

NARRATIVE

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Based on interviews and documents obtained during the investigation, the above allegation is Unsubstantiated. Unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted, and a copy of this report was provided to the Licensee/Administrator Michael 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: 04/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023

LIC9099 (FAS) - (06/04)

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