361880801-8-29-2023-56-AS-KCLS-CXKPDW-20231114101414

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880801
Report Date: 08/29/2023
Date Signed: 08/29/2023 10:43:03 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/24/2023 and conducted by Evaluator Bernadette Allen

COMPLAINT CONTROL NUMBER: 56-AS-20230824090044

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: 65	DATE:	08/29/2023
		UNANNOUNCED	TIME BEGAN:	08:35 AM
MET WITH:	Maria Carrillo-Molina		TIME COMPLETED:	10:50 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility ceiling is in disrepair.
Facility floor is in disrepair.
Facility lights are in disrepair.
Facility is malodorous.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to initiate and deliver findings for the mentioned allegations. LPA Allen met with Maria Carrillo-Molina support staff who was informed of the visit.

The investigation consisted of interviews with seven (7) residents, six (6) staff members, and observations.

The residents and staff were interviewed, all staff and residents stated that the facility experienced some water damage during 8/19/2023 through 8/21/2023. LPA observed repairs had been done in some of the rooms. The light fixtures had been replaced/repaired in room 128 and the celling did appear to have some dried water damage but there was no visible water leaking from the celling or light fixtures in the bedrooms or in any part of the facility. The central bathroom by memory care unit has been fully repaired there were no holes in the celling,walls,or floors.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

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

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 56-AS-20230824090044

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: JASMIN TERRACE AT YUCCA VALLEY	FACILITY NUMBER: 361880801
	VISIT DATE: 08/29/2023

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

Resident R1 was relocated in another room that has been repaired. LPA observed that room 130 did not have any residents in it. Maria stated that R's personal belongings had not been moved yet but would be moved today 8/29/2023. During the tour of the memory care unit LPA observed housekeeping moping the floor and it was not malodorous and LPA didn't observe the floor to be in disrepair.

Based on interviews conducted, and observations the allegations above are Unsubstantiated.

A finding of unsubstantiated means although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted with Maria Carrillo-Molina where the report was discussed and provided at the conclusion of the visit with appeal rights.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette Allen	TELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2