361880801-11-21-2023-56-AS-KCLS-CZENR6-20240112094058

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880801
Report Date: 11/21/2023
Date Signed: 11/21/2023 03:18:45 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
11/20/2023 and conducted by Evaluator Magda Malcore

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20231120225037

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: 68	DATE:	11/21/2023
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Michael Garcia, Administrator		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident developed food poisoning while in care
Staff do not ensure resident's are provided nutritious meals
Facility has pests

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced complaint visit to the facility. LPA Malcore met with Michael Garcia, Administrator and discussed the purpose of the visit. The investigation consisted of LPA facility tour, pertinent record review, interviews with residents and staff.
Regarding the allegation, resident developed food poisoning while in care, LPA toured the kitchen. Facility refrigerators and freezers were operating in a healthful manner. Pesticides and other cleaning solutions are stored away from food areas. Kitchen area was free of litter and roaches. Staff interviewed deny residents developed food poisoning while in care. Eight (8) residents interviewed deny developing food poisoning while in care.
Regarding the allegation, staff do not ensure resident's are provided nutritious meals, facility menus reflect a variety of nutritious meals. Staff interviewed deny not ensuring residents are provided nutritious meals. Six (6) out of eight (8) residents interviewed stated that meals provided are nutritious.
Regarding the allegation, facility has pest, staff interviews reveal, the facility has a monthly contract with an outside extermination company for pest control maintenance. LPA record review reveals the facility was last treated for pest control on 11/10/23. Six (6) out of (8) residents interviewed deny having roaches in their bedrooms. LPA did not observe roaches in resident's bedrooms.

Unsubstantiated

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: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

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-20231120225037

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: 11/21/2023

NARRATIVE

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Based on observations, record review, and interviews, the allegations mentioned in this report are Unsubstantiated; meaning that although the allegation 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 where this report was discussed and a copy with appeal rights was provided to Administrator 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: 11/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2023

LIC9099 (FAS) - (06/04)

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