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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 03:43:42 PM

Document Has Been Signed on 10/21/2024 03:43 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 - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Michael GarciaTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Magda Malcore conducted an unannounced case management based on deficiencies observed during today’s visit, 10/21/24. LPA met with Administrator, Michael Garcia and was informed of the visit.

On 10/21/24, LPA's record review of resident's files, reveals resident #1(R1) was sent to the hospital by ambulance on 6/18/24, 9/24/24, and 10/08/24. Resident#2(R2) was sent to the hospital by ambulance on 7/06/24 and 9/23/24. Resident#3 (R3) had a physical altercation with Resident #4(R4). R4 sustained injuries and facility staff called law enforcement. During today's visit, LPA observed dark discoloration around Resident #5 (R5's) eye. Staff #1 (S1) informed LPA is was due to a fall and Hospice was notified. LPA review of Regional Office files and interview with the Administrator reveals, staff did not submit a written report to Community Care Licensing on these incidents which involved the health and safety of the residents in care.

On 10/21/24, LPA toured the memory care area of the facility. During the tour, LPA observed a strong odor in the hallway. S1 stated that R1 had just been changed. However, LPA observed R1 was in the activities room which was a lengthy distance from R1' room. LPA entered R1's room, noticed the strong odor and noticed that the room floor was sticky.

Deficiencies are being cited in accordance with Title 22, Division 6, of the California Code of Regulations (see LIC809D). A civil penalty of $250 is hereby assessed today for repeat violations within a 12-month period for regulation 87211(a)(1)(D)previously cited on 12/09/23. Another civil penalty is also being assessed for repeat violation within a 12-month period for regulation 87303(a) previously cited on 8/23/24. The Administrator was informed civil penalties will continue to accrue $100 per day until the deficiency is corrected.
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 03:43 PM - It Cannot Be Edited


Created By: Magda Malcore On 10/21/2024 at 02:40 PM
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 B
10/31/2024
Section Cited
CCR
87211(a)(1)(D)

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87211 (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency...within seven days of the occurrence of...(D)Any incident which threatens the welfare, safety or health of any resident...This requirement is not met as evidenced by:
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The Administrator stated that changes have been made as to staff self-reporting incidents to the Licensing Agency. The Administrator has agreed to submit LIC624 reports to the licensing agency on the incidents by POC due date
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The Licensee did not comply with the section cited above by not reporting incidents that threatened the health and safety of R1, R2, R3, R4, and R5; which poses a potential 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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Document Has Been Signed on 10/21/2024 03:43 PM - It Cannot Be Edited


Created By: Magda Malcore On 10/21/2024 at 02:51 PM
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 B
10/31/2024
Section Cited
CCR
87303(a)

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87303(a) The facility shall be clean, safe, sanitary and in good repair at all times...this requirement is not met as evidenced by:
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During LPA's visit, staff mopped R1's bedroom floor and odors were removed. No further action required.
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The Licensee did not comply with the section cited above by not maintaining resident's room and facility hallway free of odor; and not maintaining resident's floor clean; which poses a potential health, safety and personal rights risks 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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/21/2024
NARRATIVE
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An exit interview was conducted where this report and correction plans were discussed. A copy of this report with appeal rights was provided to the Administrator at the conclusion of the visit.
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
LIC809 (FAS) - (06/04)
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