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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880702
Report Date: 12/09/2021
Date Signed: 12/09/2021 10:02:22 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 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/07/2021 and conducted by Evaluator Shaunte Henry
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210407124520
FACILITY NAME:MIRAGE ELDERLY CAREFACILITY NUMBER:
331880702
ADMINISTRATOR:THEOBALD, VICTORIAFACILITY TYPE:
740
ADDRESS:1 CALAIS CIRTELEPHONE:
(760) 328-6400
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY:6CENSUS: 3DATE:
12/09/2021
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Victoria Theobald, licensee/administratorTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Resident sustained pressure injuries while in care.
Facility did not notify the resident’s responsible party of change in condition.
INVESTIGATION FINDINGS:
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On 12/9/21 Licensing Program Analyst (LPA) Shaunte Henry conducted an unannounced visit for the purpose of delivering the findings to the above allegations LPA met with Victoria Theobald, explained the nature of the visit and was granted entry.

The investigation, which consisted of interviews and file review revealed the following:

Resident sustained pressure injuries while in care:
During an interview, the licensee reported that Resident 1(R1) developed wounds. The wounds were being treated by a hospice care team. The LPA observed hospice documents that indicates that R1 was receiving wound care for wounds to the left hip and right big toe dated 6/8/20. R1 was admitted to the facility on 5/15/20.
***Continued on 9099C**
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
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-20210407124520
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: 12/09/2021
NARRATIVE
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 ***Continued from 9099***

Facility did not notify the resident’s responsible party of change in condition.
During an interview with the licensee, the licensee stated that she did notify R1’s family regarding the change in R1’s condition. Interviews with R1’s family suggests the licensee did not inform them of R1’s medical condition until the day before R1 passed away, which was 9/21/20. File review of the hospice documentation confirmed the licensee notified hospice, but did not confirm that the licensee notified the responsible party. The licensee was not able to provide documentation that the family was notified of R1’s change in condition. The LPA was not able to provide proof of any special incident reports that would have been submitted by the licensee to the department that supports the licensee’s statement, therefore the allegation that the facility did not notify the resident’s responsible party of change in condition is SUBSTANTIATED.

Based on LPAs observations and interviews, which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is 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, LIC 811 and appeal rights were provided to Victoria Theobald.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
LIC9099 (FAS) - (06/04)
Page: 5 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
04/07/2021 and conducted by Evaluator Shaunte Henry
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210407124520

FACILITY NAME:MIRAGE ELDERLY CAREFACILITY NUMBER:
331880702
ADMINISTRATOR:THEOBALD, VICTORIAFACILITY TYPE:
740
ADDRESS:1 CALAIS CIRTELEPHONE:
(760) 328-6400
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY:6CENSUS: 3DATE:
12/09/2021
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Victoria Theobald, licensee/administratorTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Facility did not seek timely medical treatment for resident.
Facility did not notify health professionals of change in resident’s condition
INVESTIGATION FINDINGS:
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On 12/9/21 Licensing Program Analyst (LPA) Shaunte Henry conducted an unannounced visit for the purpose of delivering the findings to the above allegations LPA met with Victoria Theobald, explained the nature of the visit and was granted entry.

The investigation, which consisted of interviews and file review revealed the following:

Facility did not seek timely medical treatment for resident:
LPA interviewed supervisor at the hospice agency. Interview suggested that the facility staff did contact hospice when R1 experienced a change in condition. Hospice documents indicates hospice staff visited R1 at least 3 times a week between 5/15/20 up into R1’s death on 9/21/20.
***Continued on LIC 9099C***
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20210407124520
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: 12/09/2021
NARRATIVE
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***continued from 9099***

The LPA attempted to interview additional hospice staff, however the employees 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. The 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.

Facility did not notify health professionals of change in resident’s condition:
The licensee denied failing to notify health professional (hospice) of R1’s change condition. The LPA observed that R1’s declining condition was documented in the hospice care plan. A review of R1’s hospice documents indicates the family was updated of R1’s condition. Interviews with R1’s family denied being notified of R1’s change in condition. During an interview with the director, it was reported that the licensee kept the hospice agency informed of R1’s health condition. Therefore, based on conflicting interviews obtained from the licensee, hospice staff, and family, the allegation: staff did not notify health professionals of R1’s change in health condition, is UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED at this time. An exit interview was conducted where this report was provided to Victoria Theobald.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20210407124520
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: 12/09/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/09/2021
Section Cited
CCR
87466
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Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning
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The licensee will provide staff training, review the cited regulation in its entirety, sign/date and return the regulation to the department by the POC date.
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and that appropriate assistance is provided when such observation reveals unmet needs. This requirement was not met as evidenced by:
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Resident 1 (R1) developed pressure injuries in June of 2020. R1 was receiving wound care by a hospice agency for those pressure injuries.
Type B
12/09/2021
Section Cited
CCR
87468.1(a)(8)
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Personal Rights of Residents in all Facilities Residents in all residential facilities for the elderly shall have all of the following personal rights… (8) to have their representatives regularly informed
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The licensee will review the cited regulation in it’s entirety, sign, date and provide proof to the department by the POC date.

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 by the licensee of activities related to health care services, including on going evaluations, as appropriate to their needs. This requirement was not as evidenced by:
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The licensee denied failing to provide R1’s responsible party with the change in condition. The licensee was not able to provide proof that the family was notified.
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 BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 5