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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880801
Report Date: 08/09/2023
Date Signed: 08/09/2023 03:09:37 PM


Document Has Been Signed on 08/09/2023 03:09 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: 74DATE:
08/09/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Michael Garcia, AdministratorTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced Plan of Correction (POC) visit to the facility to follow up on a deficiency. LPA met with Michael Garcia and discussed the purpose of the visit.

On 7/31/23, a deficiency was issued for not providing resident with follow-up medical care. Administrator stated that the resident did have a follow-up visit with resident’s doctor and would provide proof by POC date 8/01/23. During today's visit (8/09/23), POC is cleared.

A civil penalty was accessed today for failure to correct the deficiency by POC date.



An exit interview was conducted where this report was discussed and a copy of this report with appeal rights was 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: 08/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2023
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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