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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880801
Report Date: 09/19/2023
Date Signed: 09/19/2023 03:06:02 PM

Unsubstantiated


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
07/20/2023 and conducted by Evaluator Magda Malcore
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230720103450
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:
09/19/2023
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Michael Garcia, Administrator TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff continues to steal medications
Staff did not provide proper shower assistance to residents in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced complaint visit to the facility. LPA met with Michael Garcia, administrator and discussed the purpose of the visit.
Regarding allegation, staff continues to steal medications, Administrator denies witnessing staff stealing resident's medications. Staff interviewed deny stealing resident’s medication nor have they witnessed other staff stealing resident’s medications. Residents interviewed deny that staff have stolen their medications.
Regarding allegation, staff did not provide proper shower assistance to residents in care, Administrator and staff interviews deny not providing proper shower assistance to residents in care. Five (5) out of (6) residents interviewed stated that staff do provide them with proper shower assistance.
Based on pertinent record review and interviews with relevant parties, the allegation is Unsubstantiated.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
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 4
Control Number 56-AS-20230720103450
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: 09/19/2023
NARRATIVE
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A finding of Unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.
An exit interview was conducted where this report was discussed and provided with appeal rights to the administrator at the conclusion of the visit.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
07/20/2023 and conducted by Evaluator Magda Malcore
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230720103450

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:
09/19/2023
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Michael Garcia, Administrator TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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2
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9
Staff mismanaged resident's medication
Residents in care do not have activities
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced complaint visit to the facility. LPA met with Michael Garcia, Administrator and discussed the purpose of the visit.
Regarding allegation, staff mismanages resident’s medication, LPA toured the medication room with the assistance of facility staff. LPA reviewed five (5) resident’s centrally stored medication records and medications. LPA observed medications for (2) residents were missing. Staff was unable to locate the medications.
Regarding allegation, residents in care do not have activities, Administrator interview reveals that both staff assigned to conduct activities are on medical leave. Administrator is attempting to find other staff to assist with activities. Four (4) out of (6) residents interviewed stated that the facility does not have activities for them.
Based on pertinent record review and interviews with relevant parties, the allegation is Substantiated. A finding that the complaint is Substantiated means that the allegation(s) is valid because the preponderance of the evidence standard has been met.An exit interview was conducted where reports (LIC9099&LIC9099-D) were discussed and provided with appeal rights to the administrator at the conclusion of the visit.



Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 56-AS-20230720103450
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: 09/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/20/2023
Section Cited
CCR
87464(f)(2)
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87464Basic Services(f)Basic services shall at a minimum include:(2) Safe and healthful living accommodations and services. This requirement is not met as evidenced by:
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Administator shall read and submit a self-certification of understanding to the licensing agency by POC date.
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medications for (2) residents were missing. Staff was unable to locate the medication; which poses an immediate health, safety, and personal rights risks to persons in care.
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Type B
09/29/2023
Section Cited
CCR
87464(f)(7)
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87464Basic Services(f)Basic services shall at a minimum include:(7)A planned activities program which includes social and recreational activities appropriate...this requirement is not met as evidenced by:
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Administator shall read and submit a self-certification of understanding to the licensing agency by POC date.
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Facility staff assigned to activities are on medical leave. Four (4) out of (6) residents interviewed stated that the facility does not have activities for them.
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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: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4