361880801-8-9-2023-56-AS-EMAN-CWZN58-20231027100906

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880801
Report Date: 08/09/2023
Date Signed: 08/09/2023 03:00:31 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: 74	DATE:	08/09/2023
		UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Michael Garcia, Administrator		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Staff did not refill resident's medication(s) in a timely manner.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to continue complaint investigation and deliver findings on the above allegation. LPA met with Administrator Michael Garcia who was informed of today’s visit.

The investigation consisted of LPA observations, file review, and interviews with relevant parties.

Regarding the allegation, Staff did not refill resident's medication(s) in a timely manner, facility written notes reveal that Resident's #1 (R1) medication was ordered on 6/26/23, however the resident's medication was not received until 7/13/23. Administrator was not able to confirm the reason for R1's medication delay. Interviews with staff reveal that medication from R1's hospital sometimes takes longer that 10 days to receive. Facility had no documentation of follow-up contact with resident's hospital and/or Doctor to ensure resident's medication is received in a timely manner.

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: 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.

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: 08/09/2023

NARRATIVE

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Based on evidence obtained during the investigation, the 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.

An exit interview was conducted where reports LIC9099 and LIC9099-D were discussed and a copy of the reports with Appeal Rights was provided to Administrator Michael Garcia 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: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/09/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/10/2023 Section Cited CCR 87464(f)(6)	1 2 3 4 5 6 7	87464 Basic Services (f)Basic services shall at a minimum include:(6) Arrangements to meet health needs. This requirement is not met by:	1 2 3 4 5 6 7	Administator shall read and submit a self-certification of understanding to the licensing agency by POC date.
	8 9 10 11 12 13 14	Facility did not refill resident's medication in a timely manner and did not follow-up on the delay of resident's medication.	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: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

LIC9099 (FAS) - (06/04)

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