331880702-5-24-2021-18-AS-NBRN-C3KSWV-20210601141454

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880702
Report Date: 04/20/2021
Date Signed: 05/24/2021 08:42:22 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-26
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/25/2020 and conducted by Evaluator Shaunte Henry

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200925161707

FACILITY NAME:	MIRAGE ELDERLY CARE		FACILITY NUMBER:	331880702
ADMINISTRATOR:	THEOBALD, VICTORIA		FACILITY TYPE:	740
ADDRESS:	1 CALAIS CIR		TELEPHONE:	(760) 328-6400
CITY:	RANCHO MIRAGE	STATE: CA	ZIP CODE:	92270
CAPACITY:	6	CENSUS: 6	DATE:	04/20/2021
		UNANNOUNCED	TIME BEGAN:	12:21 PM
MET WITH:	Victoria Theobald, Licensee/Administrator		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Facility staff did not seek timely medical attention
Staff did not notify resident's authorized representative of change in health condition
Staff failed to provide adequate care and supervision to resident

INVESTIGATION FINDINGS:

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On 5/10/21 Licensing Program Analyst (LPA) Shaunte Henry conducted an unannounced visit via phone to deliver the findings to the above allegations. LPA spoke with licensee/administrator Victoria Theobald and explained the purpose of the call.

The investigation, which consisted of document review and interviews revealed the following:
1)Facility staff did not seek timely medical attention:
LPA interviewed supervisor at Hospice agency. Interview suggested that the facility staff did seek medical attention for Resident 1 (R1) in a timely manner. LPA attempted to interview additional hospice staff, but the employee’s no longer work for the company and could not be contacted. LPA interviewed the licensee. The Licensee stated that anytime a change of condition was observed, hospice was notified. Licensee denied not seeking medical attention in a timely manner. Therefore, based on conflicting information obtained during interviews, the allegation, facility staff did not seek timely medical attention is unsubstantiated.

***continued on 9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20200925161707

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MIRAGE ELDERLY CARE	FACILITY NUMBER: 331880702
	VISIT DATE: 04/20/2021

NARRATIVE

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***Continued from 9099***

2)Staff did not notify resident's authorized representative of change in health condition.
The administrator denied failing to notify the authorized representative of a change in R1's condition. (R1) declining condition was documented in the hospice care plan. LPA conducted a file review and observed notes in the hospice plan when family was notified of the resident’s condition. Interviews were conducted with (R1) family who denied being notified of change in (R1) condition. Therefore, based on conflicting interviews obtained from Licensee, hospice staff, and family, the allegation: staff did not notify resident's authorized representative of change in health condition, is unsubstantiated.

3)Staff failed to provide adequate care and supervision to resident
LPA conducted file review and interviewed staff. Licensee denied not providing adequate care and supervision to (R1). LPA interviewed hospice agency staff. Interviews revealed that R1 was provided adequate care and supervision at Mirage Elderly Care, where R1 resided.

Based on interviews conducted and file review, LPA could not prove that staff failed to provide adequate care and supervision to resident. Therefore, based on file review and interviews conducted with staff, staff failed to provide adequate care and supervision to resident is unsubstantiated. Based on conflicting interviews and file review, the allegations: facility staff did not seek timely medical attention, staff did not notify resident's authorized representative of change in health condition, and staff failed to provide adequate care and supervision to resident is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are unsubstantiated at this time. An exit interview was conducted where this report was discussed with and provided to Victoria Theobald.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 05/10/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/10/2021

LIC9099 (FAS) - (06/04)

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