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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880801
Report Date: 10/21/2024
Date Signed: 10/21/2024 02:03:50 PM

Document Has Been Signed on 10/21/2024 02:03 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:JASMIN TERRACE AT YUCCA VALLEYFACILITY NUMBER:
361880801
ADMINISTRATOR/
DIRECTOR:		MICHAEL GARCIAFACILITY TYPE:
740
ADDRESS:55425 SANTA FE TRAILTELEPHONE:
(760) 365-0887
CITY:YUCCA VALLEYSTATE: CAZIP CODE:
92284
CAPACITY: 85CENSUS: 68DATE:
10/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Michael GarciaTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced case management visit to the facility. LPA met with Administrator, Michael Garcia, and provided the following report regarding the Department's investigation of the death of Resident#1 (R1). Investigation included interviews and review of records for R1.

Investigation revealed that on December 21, 2022, R1 was observed with an abrasion and open sore on right knee. R1 complained that leg hurt. R1 was sent to the hospital around 2:00 pm and returned to the facility between 6:00-6:30 pm on same day. R1 was observed to be walking with a gait. R1 was then observed to leave the facility by self around 7:00 pm.

Around 8:30 pm, local law enforcement came to the facility to inform staff that R1 was struck by a vehicle while attempting to cross the highway. Law enforcement informed staff that R1 was transported to the hospital and died around 10:00 pm.

Physician's report dated December 12, 2022, indicated that R1 was ambulatory and was “unable to leave facility unassisted.” In addition, report indicated that R1 “has episodes of forgetting, being distracted.” On December 21, 2022, facility staff allowed R1 to leave facility by self and failed to provide R1 with adequate observation and supervision to meet R1 needs. Soon after leaving the facility, R1 crossed a nearby highway and subsequently was struck and killed by a vehicle.

The Licensee is cited per violation of Title 22, California Code of Regulations. In addition, this violation posed an immediate Health and Safety risk to resident(s) in care. An Immediate Civil Penalty of $500 is being assessed. The licensee was also informed that an additional civil penalty may be assessed based on Health and Safety Code § 1569.49.


An exit interview was conducted where reports LIC809, LIC 809-D, LIC421IM, and appeal rights were discussed and provided to Administrator Garcia. Signature on this report acknowledges receipt of the appeal rights.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 10/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/21/2024
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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Document Has Been Signed on 10/21/2024 02:03 PM - It Cannot Be Edited


Created By: Magda Malcore On 10/21/2024 at 11:35 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
RIVERSIDE, CA 92507

FACILITY NAME: JASMIN TERRACE AT YUCCA VALLEY
FACILITY NUMBER: 361880801

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/23/2024
Section Cited
HSC
1569.269(a)(6)

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H&S:1569.269(a)(6) Enumerated rights; severability: Residents of residential care facilities for the elderly shall have all of the following rights: To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs. This requirement is not met at evidenced by:
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The Licensee/Adminstrator has agreed to provide in-service staff training on regulations: 87466 Observation of the resident, 87463 reappraisals and 87461 Mental Condition as submit to proof of training to the Licensing Agency by POC due date.

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The Licensee did not comply with the section cited by facility staff were not competent in meeting R1 needs. Facility staff failed to properly supervise R1. Following R1 leaving facility premises on December 21, 2022, R1 was struck by a vehicle and killed while attempting to cross a highway. This posed an immediate health, safety or personal rights risk to persons in care.
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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 Clemons
LICENSING EVALUATOR NAME:Magda Malcore
LICENSING EVALUATOR SIGNATURE:
DATE: 10/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/21/2024


LIC809 (FAS) - (06/04)
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