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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880801
Report Date: 03/02/2024
Date Signed: 03/02/2024 11:35:46 AM

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
07/25/2023 and conducted by Evaluator Magda Malcore
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230725161544
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:
03/02/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Michael Garcia - AdministratorTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Staff moved resident to memory care without responsible party consent
Staff failed to safeguard resident's personal belongings
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to conclude the investigation on the above allegations. LPA met with Administrator, Michael Garcia, and discussed the purpose of the visit.

Regarding the allegation, staff moved resident to memory care without responsible party consent, interviews with staff and resident #1 (R1’s) responsible party reveal, there is not enough evidence to corroborate the allegation.
Regarding the allegation, staff failed to safeguard resident’s personal belongings, on 7/24/23, Community Care Licensing Division Regional office received an incident report stating that on 7/19/23, resident #2 (R2) stole personal belongings from resident #3 (R3) and resident #4 (R4). On 7/20/23, staff reported the theft to the Sheriff’s Department. LPA record review reveals the facility does have a written theft and loss policy. Interviews with (R3) and (R4) reveal, there is not enough evidence to corroborate the allegation.
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: 03/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2024
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 5
Control Number 56-AS-20230725161544
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: 03/02/2024
NARRATIVE
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Based on LPA pertinent document review and interviews, the above allegations are Unsubstantiated. An Unsubstantiated finding means, although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

An exit interview was conducted where the Licensing reports were discussed and copies were provided to Administrator Garcia 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: 03/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
07/25/2023 and conducted by Evaluator Magda Malcore
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230725161544

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:
03/02/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Michael Garcia - AdministratorTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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9
Uncleared staff working at the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to the facility to deliver findings on the above allegation. LPA met with Administrator, Michael Garcia, and discussed the purpose of the visit.

Regarding the allegation, uncleared staff working at the facility, it is alleged staff #1 (S1) is working at the facility without a background clearance. LPA record review reveals, S1 has a signed criminal record statement and a criminal record clearance with the California Department of Social Services.
Based on LPA record review, the above allegation is Unfounded. An Unfounded finding means, the allegation is false, could not have happened, and/or is without a reasonable basis.
An exit interview was conducted where this report was discussed and a copy of this report was provided to Administrator Garcia at the conclusion of the visit.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 248-0349
LICENSING EVALUATOR NAME: Magda MalcoreTELEPHONE: 951-248-0316
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2024
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 5
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
07/25/2023 and conducted by Evaluator Magda Malcore
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230725161544

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:
03/02/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Michael Garcia - AdministratorTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Facility does not keep current and complete resident records
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced visit to facility to deliver findings on the above allegation. LPA met with Administrator, Michael Garcia and discussed the purpose of the visit.

Regarding the allegation, facility does not keep current and complete resident records, it is alleged resident’s physician’s reports are not current and are incomplete. LPA review of eight (8) resident records reveals the following: resident #1 (R1’s) last medical exam on file was conducted on 6/23/2022, due to R1’s cognitive condition an annual medical assessment is required. Resident #2 (R2) physician’s report was missing physician’s signature. Resident #5 (R5) did not have a complete physician's report or a medical assessment on file.
Based on LPA record review, the allegation is Substantiated. A Substantiated finding means that the allegation is valid because the preponderance of the evidence standard has been met.
A deficiency has been cited per California Code of Regulations, Title 22. An exit interview was conducted where the Licensing reports and plan of corrections were discussed. Copies of the reports with Appeal Rights were provided to Administrator Garcia at the conclusion of 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: 03/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20230725161544
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: 03/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2024
Section Cited
CCR
87506(a)
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Resident Records.The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility…this requirement is not met as evidenced by:
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The Administrator stated that both R2 and R5 no longer reside at the facility. The Licensee/Administrator shall submit to the Licensing Agency a statement of understanding on the regulation cited by POC due date.
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resident #1 (R1’s) last medical exam on file was conducted on 6/23/2022, due to R1’s cognitive condition an annual medical assessment is required. Resident #2 (R2) physician’s report was missing physician’s signature. Resident #5 (R5) did not have a complete physician's report or a medical assessment on file, which poses a potential health, safety, or personal rights risk to persons in care.
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The Licensee/Administrator shall submit to the Licensing agency proof of R1's current physician's report or medical assesment as per regulation 87458 medical assessments.
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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: 03/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5