361880801-8-1-2023-56-AS-MMAE-CUB2LL-20230801172942

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361880801
Report Date: 08/01/2023
Date Signed: 08/01/2023 05:30:13 PM

Document Has Been Signed on 08/01/2023 05:30 PM - 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 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: 73	DATE:	08/01/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Maria Cervantes Molina & Michael Garcia		TIME COMPLETED:	05:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility to conduct a required annual inspection. LPA met with Maria Carrillo Molina, Dietary Supervisor and Michael Garcia, Administrator and discussed the purpose of the visit. The facility is a Residential Care Facility for the Elderly (RCFE). License capacity of (85) with a current census of (73). Hospice waiver for (10) residents. LPA conducted an overall inspection of the facility, which included, but was not limited to, the following: LPA inspected the facility inside and out. Indoor and outdoor passageways are free of obstruction. The facility has sufficient lighting and is maintained at a comfortable temperature. Fireplace is adequately screened. Facility has no outdoor bodies of water. Facility has sufficient indoor and outdoor furniture in good repair for residents in care. Facility has a covered outdoor patio area. However, the outdoor space for Dementia residents is not completely enclosed with open access to the street. Deficiency cited. LPA inspected the kitchen. Hot water temperature is maintained at degrees 109 degrees F. Facility has sufficient non-perishable and perishable food supply for the number of residents in care. A monthly menu is posted in the kitchen. However, LPA observed roaches and insects on several areas of the kitchen. Staff stated that an exterminator is scheduled to treat the facility on August 3rd. Deficiency cited LPA inspected (10) resident bedrooms. Bedrooms are equipped with mattresses, nightstands, pillows, chairs, and storage space. Bedrooms have sufficient linen and lighting.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

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

LIC809 (FAS) - (06/04)

Page: 3 of 13

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
	VISIT DATE: 08/01/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA inspected client bathrooms and central bathroom. Bathrooms are equipped with handrails, shower chairs and operating in safe conditions. The hot water temperature tested in all bathrooms between 105 and 112 degrees F. However, upon turning on the light of the central bathroom, LPA observed bugs scattering around the floor. Staff stated that an exterminator is scheduled to treat the facility on August 3rd. Deficiency cited.

LPA observed the facility is equipped with operating carbon monoxide alarms. Facility has operating telephone service on the premises. Posters such as personal rights, ombudsman contact poster, Licensing complaint telephone number, emergency phone numbers are posted in a common area.

Disinfectants, cleaning solutions, and toxins are kept locked and inaccessible to residents in care.

LPA reviewed client medications are kept in a safe and locked cabinet inaccessible to residents in care. All medication are labeled and administered as prescribed.

LPA reviewed staff files for fingerprint Clearances/Exemptions, training certifications, health screening, employee rights and applications. LPA found that staff #1 did not have the required health screening. deficiency cited.

LPA reviewed resident files for admissions agreements, physician's reports, needs service plans Personal Rights: Residential Care for the Elderly. LPA found resident #1 and resident #2 files were missing admissions agreements and Resident #3 file had an incomplete physician's report. Deficiency cite.

Deficiencies are being cited during today's visit. An exit interview was conducted where reports (LIC809/LIC809D) were discussed and a copy of the reports with appeal rights was provided to Maria Carrillo Molina 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: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

LIC809 (FAS) - (06/04)

Page: 10 of 13

Document Has Been Signed on 08/01/2023 05:30 PM - 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: 08/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(27)

General Food Service Requirements

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. LPA observed roaches and insects on several areas of the kitchen; Which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/03/2023
	Plan of Correction
1 2 3 4	Administrator to provide proof of treatment by POC date

Type A

Section Cited

CCR

87705(h)

Care of Persons with Dementia

(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. The outdoor space for Dementia residents is not completely enclosed with open access to the street. which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/03/2023
	Plan of Correction
1 2 3 4	Administrator/Licensee to provide proof of correction that the area is completely enclosed by POC date.

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 Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

LIC809 (FAS) - (06/04)

Page: 11 of 13

Document Has Been Signed on 08/01/2023 05:30 PM - 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: 08/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87506(b)(15)

Resident Records

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above. LPA found two (2) resident files with missing admissions agreements; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/15/2023
	Plan of Correction
1 2 3 4	Administrator/Licensee to provide copies of admissions agreement for Resident #1 and Resident #2 to licensing agency by poc date

Type B

Section Cited

CCR

87507(c)

Admission Agreements

(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in. LPA observed missing admissions agreements which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/15/2023
	Plan of Correction
1 2 3 4	Administrator shall submit a statement of understanding of the above regulation by due date.

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 Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

LIC809 (FAS) - (06/04)

Page: 12 of 13

Document Has Been Signed on 08/01/2023 05:30 PM - 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: 08/01/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. T
	Deficient Practice Statement
1 2 3 4	This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above. Staff#1 did not have required health screening; which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 08/11/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator to submit health screening records for staff #1 to the licensing agency by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 08/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2023

LIC809 (FAS) - (06/04)

Page: 13 of 13