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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880801
Report Date: 07/31/2023
Date Signed: 07/31/2023 01:20:00 PM


Document Has Been Signed on 07/31/2023 01:20 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 VALLEYFACILITY NUMBER:
361880801
ADMINISTRATOR:MICHAEL GARCIAFACILITY TYPE:
740
ADDRESS:55425 SANTA FE TRAILTELEPHONE:
(760) 365-0887
CITY:YUCCA VALLEYSTATE: CAZIP CODE:
92284
CAPACITY:85CENSUS: 73DATE:
07/31/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Michael Garcia, AdministratorTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Magda Malcore prompted a case management visit to the facility for deficiencies identified through complaint investigation 56-AS-20230504153119. LPA met with Administrator, Michael Garcia.

Criminal Record Clearance: LPA review of facility records and staff interviews reveal that Staff #1 (S1) was working at the facility without background clearance when an incident occurred at the facility on 4/28/23. LPA determined through Guardian (personnel management system) that S1 was associated to the facility on 4/07/23 and did not have a criminal record clearance. The Administrator stated that S1 resigned and is no longer employed at the facility. A deficiency is being cited in accordance with the California Code of Regulations, Title 22, see LIC809D.

Furthermore, LPA review of facility compliance history reveals facility was cited for the same deficiency on 1/12/23 for having an uncleared staff working at the facility.

An immediate civil penalty of $1000 is hereby assessed today, 7/31/23, for repeat violation within a 12-month period. The Administrator was informed that a civil penalties will continue to accrue of $100 per day per violation until deficiency is corrected
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:
DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2023
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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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: 07/31/2023
NARRATIVE
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Incidental Medical and Dental Care: LPA review of facility records and staff interviews reveal on 4/28/23, resident #1 (R1) sustained injuries to their face and buttocks due to a fall. The Administrator stated that he did discuss with staff as to why medical services where not call and stated that the Medtech deemed not necessary. LPA found no documentation of staff arranging medical services for R1’s injuries. An incident report was provided to the Licensing Agency. On 6/11/23, staff found R1 on the floor with injuries in between R1’s nose and eyebrow. LPA found no documentation of staff arranging medical services for R1’s injuries. On 6/15/23, R1 was taken to the hospital for a possible fall and hip injury. R1 discharge reveal that a follow-up visit with primary care physician is needed with 1-2 days. The Administrator stated that R1's daughter was taking R1 to their doctor for a follow-up. Administrator stated that he will follow-up and provide the licensing agency documentation of follow-up with primary care physician's visit. A deficiency is being cited in accordance with the California Code of Regulations, Title 22, see LIC809D.

Reporting Requirements: LPA review of facility records and licensing agency records reveal that the licensee did not provide the licensing agency with written reports regarding R1 injuries which occurred on 6/11/23 and 6/15/23. Administrator provided LPA with written incident reports and stated the he will provide proof that the incident was provided to the licensing agency within the required 7 days. A deficiency is being cited in accordance with the California Code of Regulations, Title 22, see LIC809D.

Furthermore, LPA review of facility compliance history reveals, facility was cited for the deficiency on 4/03/23 for not reporting an incident regarding a resident in care to the licensing agency.

An immediate civil penalty of $1000 is hereby assessed today, 7/31/23, for repeat violation within a 12-month period. The Administrator was informed that civil penalties will continue to accrue of $100 per day per violation until deficiency is corrected.

An exit interview was conducted where reports (LIC809/LIC809-D) were discussed and copies with appeal rights were provided to the administrator at the conclusion of the visit.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 07/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 07/31/2023 01:20 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: 07/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/01/2023
Section Cited
CCR
87355(e)(1)

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Criminal Record Clearance (e)All individuals subject to a criminal record review...prior to working...in a licensed facility shall...(1)Obtain a California clearance or a criminal record exemption...This requirement is not met as evidenced by:
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Administrator stated S1 is no longer employed at the facility. Administrator to submit a statement of understanding that the facility will ensure that all staff and/or volunteers are criminally cleared prior to start date and submit statement to the Licensing agency by POC date.
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Facility records and staff interviews reveal, Licensee did not ensure a criminal record clearance was obtained for Staff #1 (S1) prior to employment, which poses an immediate health, safety, and personal rights risk to persons in care.
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Type A
08/01/2023
Section Cited
CCR87465(a)(1)

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Incidental Medical & dental care (a) A plan..shall be by compliance with the following: (1)The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions & needs of residents. This requirement is not met as evidenced by:
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Administrator to provide proof of R1 follow-up visit with primary physician's to the licensing agency by POC date.
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Based on interviews and record review, R1 had multiple physical injuries between 4/28/23 and 6/11/23 that required follow-up medical care. However, it was not until 6/15/23, when R1 sustained subsequent injuries that R1 was sent to the hospital, which poses and immediate health, safety and personal rights risks to residents in care.
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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: 07/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 07/31/2023 01:20 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: 07/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/07/2023
Section Cited
CCR
87211(a)(1)(D)

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REPORTING REQUIREMENTS (a)Each licensee shall furnish to the licensing agency…(1)A written report…within seven days...(D)Any incident which threatens the welfare, safety or health of any resident…This requirement is not met by:
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The Administrator provided LPA with one (1) incident report. Administrator provide the additional incident report by shall provide by POC date.
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The licensee did not provide the licensing agency with written reports regarding R1 injuries which occurred on 6/11/23 and 6/15/23 with 7 days; which poses a potential health, safety or personal rights risk to persons in care.
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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: 07/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/31/2023
LIC809 (FAS) - (06/04)
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