<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880801
Report Date: 03/11/2025
Date Signed: 03/11/2025 11:30:07 AM

Document Has Been Signed on 03/11/2025 11:30 AM - 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: 61DATE:
03/11/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Michael GarciaTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Magda Malcore made an unannounced visit to the facility. LPA arrived at the facility in order to conduct a case management visit to follow up on a resident death. LPA met with Maria Molina, Assisting Administrator and explained the purpose of today's visit. LPA met with Administrator Michael Garcia shortly after.

On 3/04/2025, Community Care Licensing Division receive a death report of resident #1 (R1). During today's visit, LPA collected pertinent documentation and conducted staff interviews in regards to the death of R1. Administrator Garcia stated that no official death certificate has been issued at this time but the preliminary cause of death is believed to be from possible heart failure. LPA advised the Administrator to send a copy of the death certificate the Community Care Licensing Division (CCLD) Riverside Regional Office as soon as it is available.

An exit interview was conducted where this report (LIC 809) was discussed and a copy provided to Administrator Garcia at the conclusion of the visit.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Magda Malcore
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1