361880801-6-28-2023-56-AS-EMAN-CWZN59-20231027100906

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880801
Report Date: 06/28/2023
Date Signed: 06/28/2023 01:48:19 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/27/2023 and conducted by Evaluator Magda Malcore

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230627101007

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: 76	DATE:	06/28/2023
		UNANNOUNCED	TIME BEGAN:	10:06 AM
MET WITH:	Maria Carrillo Molina, Dietary Supervisor		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Staff are withholding resident’s personal funds

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to initiate a complaint investigation. LPA met with Maria Carrillo Molina, Dietary Supervisor and explained the purpose of the visit. LPA toured the facility, obtained pertient documents and conducted interviews.

Regarding the allegation that staff are withholding residents' personal funds, On 6/26/23, Resident #1 (R1) went to see the Administrator regarding a $100 dollar check that R1 received. R1 stated that the Administrator was not as facility and did not cash the check. On 6/27/23, Staff #1 (S1) stated that (R1) had approached (S1) about a $100 dollar check. S1 stated that the Administrator is out of state and S1 did not have access to the residents' cash funds. On 6/27/23, S1 provided R1 with $20 dollars out of their own money and provided an additional $80 dollars today, 6/28/23, again out of their money. Interviews with staff confirm that the Administrator is currently out of state and returing on 7/02/23.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda Malcore	TELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023

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-20230627101007

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/28/2023

NARRATIVE

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Based on the evidence gathered during the investigation, the above allegation is SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. A deficiency is being cited according to California Code of Regulations, Title 22, Division 6 and listed on the attached LIC 9099D.

An exit interview was conducted, and a copy of this report (LIC9099 and LIC9099D) 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: 06/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 56-AS-20230627101007

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/28/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/07/2023 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	87468.1Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have the following..(3)To be free from...actions of a punitive nature, such as withholding residents’ money. This requirement is not met as evidence by the following:	1 2 3 4 5 6 7	Resident was provided with the entire funds requested. Administrator to submit to Licensing an updated resident ledger showing funds received and disbursed to resident by POC date.
	8 9 10 11 12 13 14	Staff did not provide resident with the entire money requested which poses a potential health, safety and personal rights risk to resident in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 06/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023

LIC9099 (FAS) - (06/04)

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