361880801-6-27-2023-56-AS-KCLS-CT8UXC-20230628155805

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880801
Report Date: 06/27/2023
Date Signed: 06/27/2023 02:05:40 PM

Unsubstantiated

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
12/22/2022 and conducted by Evaluator Rayshaun Nickolas

COMPLAINT CONTROL NUMBER: 56-AS-20221222161036

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: 65	DATE:	06/27/2023
		UNANNOUNCED	TIME BEGAN:	01:36 PM
MET WITH:	Andres Castaneda, MedTech		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

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Resident sustained injuries while in care.
Resident was left on the floor for an extended period of time.
Staff sleep on residents' beds while on shift.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to deliver the finding on the above allegations. LPA met with MedTech Andres Castaneda and explained the purpose of the visit. The investigation included a facility tour, file reviews, and interviews with relevant parties.

Allegation #1 “Resident sustained injuries while in care”. The allegation alleged that on December 21, 2022, resident #1 (R1) was discovered by the reporting party (RP) with a bump on the right forehead and two (2) cuts and wounds on the left leg. LPA Nickolas' interview with the RP revealed that upon discovering R1, the RP notified the administrator, and the administrator agreed to call the paramedics. LPA Nickolas' interview with the administrator confirmed that RP discovered R1 in R1's room with injuries. The administrator confirmed that the RP notified them of this discovery, and emergency services were called. LPA Nickolas' file review revealed that on December 23, 2022, our agency received an Unusual Incident/Injury Repor (LIC 624) from the facility reporting the incident. The LIC 624 also confirmed that emergency services were contacted, and R1 was taken to the hospital for sustained injuries. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun Nickolas	TELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

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-20221222161036

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: 06/27/2023

NARRATIVE

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Allegation #2 “Resident was left on the floor for an extended period of time”. The allegation alleged that on December 21, 2022, the RP discovered R1 on the floor with injuries. The allegation alleged that the R1 told the RP that they fell and were sitting on the floor for about two (2) hours. LPA Nickolas’ interview with the RP revealed that the RP was arriving on the second floor and heard someone say help. The RP stated they discovered R1 on the floor. The RP stated that after assessing the situation, they notified the administrator. LPA Nickolas’ interview with the administrator revealed that the administrator did confirm arriving in R1’s room and observing R1 on the floor. Although R1 was discovered on the floor, no witnesses can verify how long R1 was left on the floor. Therefore, the finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation #3 “Staff sleep on residents' beds while on shift”. The allegation alleged that on December 21, 2022, the RP received several complaints from residents that staff #1 (S1) and staff # 2 (S2) took naps on the resident's bed during their shift. LPA Nickolas’ interview with client #1 (C1) revealed that they denied this allegation. LPA Nickolas’ interview with client #2 (C2) confirmed the allegations. C2 stated that they permit staff to sleep on their bed. However, C2 would not provide names of the staff. LPA Nickolas’ interview with S1, revealed that S1 denied the allegation. LPA Nickolas interview with the administrator revealed that the administrator denied the allegation. The administrator also stated that C2 is no longer employed at the facility for an unrelated reason. Therefore, the finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

A finding of Unsubstantiated means 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 copy of this report was provided

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Rayshaun Nickolas	TELEPHONE: 951-255-9516
LICENSING EVALUATOR SIGNATURE:	DATE: 06/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2023

LIC9099 (FAS) - (06/04)

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