331880702-12-3-2021-18-AS-NBRN-C9RPGL-20211216101832

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880702
Report Date: 12/03/2021
Date Signed: 12/03/2021 12:31:48 PM

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 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/07/2020 and conducted by Evaluator Shaunte Henry

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200707112241

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: 3	DATE:	12/03/2021
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Victoria Theobald, Licencee/Administrator		TIME COMPLETED:	12:35 PM

ALLEGATION(S):

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Staff denied resident the ability to receive visitors.

INVESTIGATION FINDINGS:

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On 12/3/21 Licensing Program Analyst (LPA) Shaunte Henry conducted an unannounced visit for the purpose of delivering the findings to the above allegations. The LPA met with Victoria Theobald, explained the nature of the visit and was granted entry into the facility.

The investigation, which consisted of interviews and file review revealed the following:
Allegation 1: Staff denied resident the ability to receive visitors (SUBTANTIATED)
An Interview with Family (F1) revealed the licensee would not allow them to visit R1 on several different occasions. It was reported that the licensee stated that she would call the police on F1 if they attempted to visit R1 at the facility. An interview with Family 2 (F2) revealed that they drove two hours to visit R1.
***Continued on 9099C***

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021

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

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 18-AS-20200707112241

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: 12/03/2021

NARRATIVE

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***continued from 9099C***

When they arrived at the gated entrance, they called Victoria to let her know of their arrival then the licensee told them that R1 was asleep. The licensee did not open the gate to allow F2 in to visit with R1.

Based on LPAs observations and interviews, which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6) is being cited on the attached LIC9099D.

An exit interview was conducted where this report, 9099D, LIC 811 and appeal rights were 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: 12/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 5

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 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/07/2020 and conducted by Evaluator Shaunte Henry

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200707112241

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: 3	DATE:	12/03/2021
		UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Victoria Theobald, Licencee/Administrator		TIME COMPLETED:	12:35 PM

ALLEGATION(S):

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Licensee is mismanaging resident's finances

INVESTIGATION FINDINGS:

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On 12/3/21 Licensing Program Analyst (LPA) Shaunte Henry conducted an unannounced visit for the purpose of delivering the findings to the above allegations. The LPA met with Victoria Theobald, explained the nature of the visit and was granted entry into the facility.

The investigation, which consisted of interviews and file review revealed the following:
The department conducted an audit of Resident 1 (R1)'s finances for the period of February 15, 2020 through March 18, 2021. The summarized cash withdrawals and reviewed checks during this period was $66,100. R1 was admitted to Mirage Elderly Care on March 28, 2020 and passed away on February 9, 2021. The fee due to the facility by R1 totaled $51,700.
***Continued on 9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021

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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 18-AS-20200707112241

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: 12/03/2021

NARRATIVE

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***Continued from 9099***

The licensee reported that she did not receive all of the board and care payments from R1 that was owed. The balance due from R1 at the time of death was $12,800. The licensee stated that R1 was able to manage his own finances. R1's physician report dated 4/14/20 indicates R1 was absent of mild cognitive impairment and dementia. The licensee denied mismanaging R1's finances that was not accounted for. The licensee stated that R1 did have visitors and she is unsure whether or not R1 gave them cash. The licensee stated that R1 did pay a paralegal and an attorney and it is possible that those payments were in cash because R1 did not have a checkbook until January of 2021. Review of two receipts for two checks indicates R1 wrote a check dated 1/24/21 in the amount of $3,500 to a paralegal. R1 also wrote a check dated 1/28/21 in the amount of #1,050.00 to an attorney. The department was unable to determine that the licensee R1's finances, therefore this allegation was found 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 allegation is UNSUBSTANTIATED at this time.
An exit interview was conducted where this report was 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: 12/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 18-AS-20200707112241

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/03/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/03/2021 Section Cited CCR 87468.1(a)(11)	1 2 3 4 5 6 7	Personal Rights: Residents shall have the right to have their visitors to visit privately during reasonable hours and without prior notice. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The licensee shall read regulation 87468.1, sign, date and provide proof to the department by the POC date.
	8 9 10 11 12 13 14	Based on interview and file review, the licensee failed to allow Resident 1(R1) visitors on multiple occasions. This is a potential personal rights risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021

LIC9099 (FAS) - (06/04)

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