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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880801
Report Date: 04/03/2023
Date Signed: 05/01/2023 07:30:54 AM


Document Has Been Signed on 05/01/2023 07:30 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, 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:
04/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:11 PM
MET WITH:Administator/Licensee, Michael GarciaTIME COMPLETED:
03:40 PM
NARRATIVE
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On 4/3/23, Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced case management visit to the facility. LPA met with Administrator/Licensee, Michael Garcia and explained the purpose of the today’s visit. Based on document review obtained during complaint# 56-AS-20230309152937 and complaint #56-AS-20230221161840 the following deficiencies are being cited in accordance with the California Code of Regulations, Title 22:

The facility did not submit a Special Incident Report (SIR) to the Community Care Licensing Division (CCLD) to report resident 1’s (R1) fall on 1/23/23; which poses a potential health and safety risk to resident in care, see (LIC809D).

The facility did not ensure that staff 1 (S1) and staff 2 (S2) had a verifiable health screening that indicates whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. LPA found a Health Screening Report (LIC 503) which was completed by (S1) and (S2) with the physician evaluation summary left blank, no physician stamp and signature, no date of evaluation, see (LIC809D)

Plans of Corrections were reviewed and developed with Administrator/Licensee, Michael Garcia. An exit interview was conducted, a copy of this report and appeal rights was discussed and provided to Administrator/Licensee.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/01/2023 07:30 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/07/2023
Section Cited

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87412 Personnel Records(f)All personnel...shall be in good health...Good physical health shall be verified by a health screening...performed by a physician not more than six (6) months prior to or seven (7) days after employment. This condition is not met by:
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Licensee shall provide community care licensing documentation of S1 & S2 completed health screening by POC date.
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The facility did not ensure that staff 1 (S1) and staff 2 (S2) had a verifiable health screening that indicates whether the person is physically qualified to perform the duties to be assigned.
Which poses health, safety, and personal rights risk to residents in care.
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Type B
04/07/2023
Section Cited

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87211 Reporting Requirements(a)Each licensee shall furnish...reports...including ...(1)A written report shall be submitted to the licensing agency within 7 days.. of the occurrence of...(D)Any incident which threatens the welfare, safety or health...of resident. This requirement was not met by
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Licensee provided LPA with incident report on 4/3/23. Licensee will provide training to all staff regarding reporting requirements, overview of regulation and submit proof of training to Community Care Licensing by POC date

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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: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2023
LIC809 (FAS) - (06/04)
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