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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880801
Report Date: 12/09/2023
Date Signed: 12/09/2023 02:10:34 PM


Document Has Been Signed on 12/09/2023 02:10 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, 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: 68DATE:
12/09/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Michael Garcial AdministratorTIME COMPLETED:
02:15 PM
NARRATIVE
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At 1:20PM LPA arrived at the facility Michael Garcia was called directly and stated he would be arriving at the facility in 30 minutes. LPA Allen informed him of the purpose of the visit and that I would wait for is arrival.

On 8/23/2023 Licensing Program Analyst (LPA) Bernadette Allen was at the facility to initiate a complaint investigation and deliver the findings on complaint 56-AS-20230815162748.

During the course of investigation LPA discovered that the licensee did not submit a Special Incident Report (SIR) regarding the altercation between Resident 1 (R1) and Resident 2 (R2) resulting R1 going to the hospital and returning back to the facility with stiches.

Based on the information gathered during the investigation the licensee is being cited for not reporting the incident that occurred on 6/2/2023.

A deficiency is being cited in accordance with the California Code of Regulations, Title 22, see LIC809-D and LIC421FC

An exit interview was conducted where this report was discussed and a copy was provided to Michael Garcia at the conclusion of LPA’s visit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2023
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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Document Has Been Signed on 12/09/2023 02:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/10/2023
Section Cited
CCR
87211(a)(1)(D)

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REPORTING REQUIREMENTS (a)Each licensee shall furnish to the licensing agency…(1)A written report…within seven days...(D)Any incident which threatens the welfare, safety or health of any resident…This requirement is not met by:
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The Administrator has agreed to provided the SIR for the altercation between R1 and R2 by the POC 12/10/23
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The licensee did not provide the licensing agency with written reports regarding R1 injuries which occurred on 6/11/23 and 6/15/23 with 7 days; which poses a potential health, safety or personal rights risk to persons in care.
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ILS

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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: Bernadette AllenTELEPHONE: 951-897-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2023
LIC809 (FAS) - (06/04)
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