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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880801
Report Date: 10/04/2023
Date Signed: 10/04/2023 12:42:30 PM

Substantiated


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
09/29/2023 and conducted by Evaluator Javier Prieto
COMPLAINT CONTROL NUMBER: 56-AS-20230929095525
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:
10/04/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maria Molina, Assistant AdministratorTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff mishandled resident's medications

Staff did not ensure resident was transported to resident's medical appointment.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javier Prieto and LPA Paula Guitierrez arrived to the facility to conduct a complaint investigation regarding the above-mentioned allegations. LPAs met with Assistant Administrator Molina to discuss the elements of the complaint. Regarding the allegation staff mishandled resident's medications, staff #1 (S1) interviews and medical records obtained reveal the medications were prescribed for resident #1 (R1) on 09/22/23 and medication was not located for approximately 7 days, when R1 was dispensed the first dose. Regarding the allegation that staff did not ensure resident was transported to resident's medical appointment, S1 interview reveal that R1 missed a scheduled doctor's appointment on 09/19/23 due to staff miscommunication and later attended doctor's appointment on 09/22/23.
**** continued on LIC 9099C***
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
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 3
Control Number 56-AS-20230929095525
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: 10/04/2023
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 Assistant Administrator Maria Molina at the conclusion of the visit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 56-AS-20230929095525
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/06/2023
Section Cited
CCR
87465(e)
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Incidental Medical and Dental Care
For every prescription and nonprescription PRN medication for which the licensee provided assistance there shall be a signed, dated written order from the Physician, on a blank prescription, maintained in resident's file. This requirement is not met as evidence by the following:
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Administrator is to train their staff on medication dispensing and storing of medication and a copy of that training to be sent to LPA by POC date.
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Records reveal that medications were prescribed to resident #1 and medication were not located and dispensed according to doctor's orders
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Type B
10/09/2023
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care
A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: This requirement is not met as
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Administrator to send declaration to LPA on POC date indicating that staff will better communicate with residents or resident's responsible party.
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Records revealed resident #1 had an appointment on 09/19/23, missed appt and later attended on 09/22/23
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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: Javier PrietoTELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3