361880801-1-12-2023-56-AS-MBRN-CMZUHZ-20230112143645

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361880801
Report Date: 01/12/2023
Date Signed: 01/12/2023 02:37:02 PM

Document Has Been Signed on 01/12/2023 02:37 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 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: 74	DATE:	01/12/2023
TYPE OF VISIT:	Case Management - Deficiencies	ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Licensee Virginia Garcia and Administrator Michael Garcia		TIME COMPLETED:	02:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Melody Brown met with Licensee Virginia Garcia and Administrator MIchael Garcia at Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office 01/12/2023 at 01:00 PM AM to initiate a Case Management Office Visit. LPA Brown explained the purpose of the requested Office Visit. The investigation consisted of interviews and a review of pertinent documentation.

On 02/08/2022 document review, the Department observed Staff # 4 (S4) was not listed in Personnel Report Summary with date 02/28/2022. The Department Interviewed staffs and reviewed documents and it indicated S4 started working at the facility 06/2021. LPA Brown observed per records review that S4 have criminal background clearance but the facility failed to associate S4 to the facility. LPA Brown observed that the facility recently associated S4 to the facility last 08/09/2022. LPA Brown will issue a deficiency as this pose immediate risk to residents in care. In addition, LPA Brown informed Staff # 3 (S3) that per records review, S2 had criminal background clearance and associated to the facility but the facility encoded incorrect information in Guardian website. LPA Brown requested S3 to make sure correct information are used when processing criminal background clearance and S3 expressed understanding.

Civil penalty was assessed with the amount of $500.00 during the Office Visit for failure to associate/transfer S4 Criminal Background Clearance to the facility.

Moreover, the Department reviewed R2 documents and it indicated that R2's last reappraisal date was 09/2019 and the facility failed to conduct R2's reappraisal annually. Documents review indicated R2's behaviors last 11/2019 and 12/2019 and R2's aggressive act last 06/2020 but the facility failed to conduct reappraisal on R2. ***Continuation in LIC809C ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

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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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
	VISIT DATE: 01/12/2023

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LPA Brown will be issuing a deficiency as the facility failed to ensure that R1 have annual medical assessment and reappraisal done annually that includes reassessment of R2's dementia needs which pose immediate health, safety and personal rights risk to resident in care.

An exit interview was conducted where this report (LIC809), LIC809D, LIC421BG and Appeal Rights were discussed and provided to Licensee Virginia Garcia and Administrator Michael Garcia.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/12/2023 02:37 PM - It Cannot Be Edited

Created By: Melody Brown On 01/12/2023 at 11:27 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 01/12/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/13/2023 Section Cited CCR 87355(e)(2)	1 2 3 4 5 6 7	87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working...(2) Request a transfer of a criminal record clearance as specified... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated to submit signed Statement of Understanding on CCR 87355(e)(2) and submit to LPA Brown by POC due date. Licensee associated/transferred S4 Criminal Background clearance to the facility last 08/09/2022, POC cleared.
	8 9 10 11 12 13 14	Based on interview and records review, the Licensee did not comply with the section cited above by failure to associate Staff # 4 to the facility which pose immediate health, safety and personal rights risk to resident in care.	8 9 10 11 12 13 14
Type A 01/13/2023 Section Cited CCR87705(c)(5)	1 2 3 4 5 6 7	87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall... (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually...This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee stated to train all staff on CCR 87705(c)(5) and submit Training Log to LPA Brown by POC due date. Licensee stated to submit signed Statement of Understanding on CCR 87705(c)(5) to LPA Brown by POC due date
	8 9 10 11 12 13 14	Based on interview and records review, the Licensee did not comply with the section cited above by failure to ensure that R2 have annual medical assessment and reappraisal done annually which pose immediate health, safety and personal rights risk to resident in care.	8 9 10 11 12 13 14

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:

Efren Malagon

LICENSING EVALUATOR NAME:

Melody Brown

LICENSING EVALUATOR SIGNATURE:

DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

LIC809 (FAS) - (06/04)

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