361880801-12-28-2023-56-AS-KCLS-D2VLAM-20240228073522

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 361880801
Report Date: 09/25/2023
Date Signed: 12/28/2023 11:09:39 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
09/20/2023 and conducted by Evaluator Javier Prieto

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230920141310

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: 72	DATE:	09/25/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Michael Garcia, Administrator		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Resident sustained injuries due to lack of care and supervision by staff

Staff did not ensure that resident was provided fluids to prevent dehydration per client written care plan

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Javier Prieto arrived to the facility to conduct a complaint investigation regarding the above-mentioned allegations. LPA Prieto met with Administrator Garcia and discussed the elements of the complaint. LPA Prieto interviewed resident #1 (R1), staff and gathered pertinent documentation.

Regarding allegation that resident sustained injuries due to lack of care and supervision by staff.; Staff (S1) interview reveal that staff was present at the time the injury occurred to R1. S1 interview also reveal that witness did speak with S1 in person regarding R1's injury and inquiry to hydrate R1. Staffing documentation obtained to reveal additional staff was on duty at time of resident incident.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

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-20230920141310

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: 09/25/2023

NARRATIVE

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Regarding the allegation that staff did not ensure that resident was provided fluids to prevent dehydration per client written care plan.; S1 interview and documentation reveal that there is no plan of care requiring fluids to prevent dehydration for R1. S1 interview does state that R1 is provided with fluids in R1's room. LPA observed a pitcher of water, with cup, in R1's room at time of investigation.

Based on the information obtained there is not enough evidence that the resident sustained injuries due to lack of care and supervision by staff and staff did not ensure that resident was provided fluids to prevent dehydration per client written care plan. Therefore, the allegations are deemed UNSUBSTANTIATED at this time.

This report was signed by LPA Prieto and Administrator Garcia and a copy was left with the facility.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2023

LIC9099 (FAS) - (06/04)

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