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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881086
Report Date: 05/09/2023
Date Signed: 05/09/2023 10:35:45 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
08/31/2021 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210831170004
FACILITY NAME:BAYSHIRE RANCHO MIRAGEFACILITY NUMBER:
331881086
ADMINISTRATOR:KIRBY, SCOTTFACILITY TYPE:
741
ADDRESS:72201 COUNTRY CLUB DRIVETELEPHONE:
(760) 340-5999
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY:135CENSUS: 104DATE:
05/09/2023
UNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Brittany Holm, AdministratorTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Staff does not respond to resident's request for assistance in a timely manner
Staff does not ensure that resident's needs are met
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPAs) Jesse Gardner and Janette Romero arrived unannounced to deliver findings to an investigation into the allegations listed above. LPAs met with Administrator Brittany Holm and Resident Services Director Michael Maeda and explained the purpose of the visit. LPAs later during the tour of the facility.

It was alleged that staff do not respond to Residnet One's (R1) request for assistance in a timely manner. LPA conducted a review of R1’s button pushes between the dates of August 4, 2021 through August 31, 2021. During those times, R1 pushed their pendant 16 times. An average time for staff to arrive was approximately 9.15 minutes. Separately, LPA conducted interviews with other residents and found that wait times for staff to arrive generally could be hours before a button is responded to. Thus, LPA found this allegation to be SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
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 7
Control Number 18-AS-20210831170004
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BAYSHIRE RANCHO MIRAGE
FACILITY NUMBER: 331881086
VISIT DATE: 05/09/2023
NARRATIVE
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It was then alleged that R1's needs were not being met. Resident #1 (R1) was admitted to the facility on October 30, 2020 and was discharged September 4, 2021. Upon admission, R1 was noted as non-ambulatory, having general weakness with chronic knee pain. Further, R1 was wheelchair bound, not being able to transfer themselves to and from bed, per R1’s Physician’s Report dated October 13, 2020. Further upon admission, R1 had Home Health services being provided by Suncrest Home Health for wound care. R1 was recognized to need transfers by staff with a two-person assist on R1’s appraisal document. R1 was noted to have contracted services to provide R1’s oxygen through Suncrest.

It was alleged that staff ignores doctor's orders, has not kept up services for R1 such as Home Health and has allowed the R1’s oxygen certification to expire. The resident allegedly had not had oxygen for 3 months and due to not having oxygen (being a stand-alone unit that is incapable of traversing throughout the facility) had left R1 unable to leave their bed.

At some point, R1 received a COVID-19 exposure, and was transferred to the skilled nursing side of Bayshire on January 20, 2021. On January 29, 2021, upon discharge from the skilled nursing, Bayshire requested a reappraisal and updated Physician’s Report. The new report showed that R1 was non-ambulatory but capable of independently transferring themselves to and from a bed. Progress notes indicated that per R1’s doctor, R1 was to have oxygen when placed in R1’s room, and staff to monitor. Interviews with outside sources indicated that R1 had a portable oxygen machine, as they regularly saw R1 in the dining area while R1 was utilizing the oxygen.

Interviews with staff revealed that upon discharge from skilled nursing, R1 needed and received oxygen; however, staff interviews revealed that the facility did not develop a service plan to care for the oxygen and/or replace if/when necessary. Thus, the facility did not develop a plan to care for R1 and their oxygen needs. It was also alleged that R1 needed to have their ears flushed. There was not documentation provided by the facility to indicate that care was being provided.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 18-AS-20210831170004
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BAYSHIRE RANCHO MIRAGE
FACILITY NUMBER: 331881086
VISIT DATE: 05/09/2023
NARRATIVE
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LPA was provided Suncrest Home Health documents by the facility dated February 11, 2021 through August 30, 2021. The documents indicated that Suncrest Home Health was providing weekly wound care to R1’s left knee and left great toe. It was alleged that on March 31, 2021, R1’s toe had gotten infected. A review of Suncrest notes on March 29, 2021 did not indicate that R1’s toe was, in fact, infected, but rather regular service to the wound. On April 1, 2021, Suncrest noted R1’s toe had shown no significant change. On August 30, 2021, notes indicated that R1’s toe was healing well.

LPA reviewed records and found that on on March 3, 2021, staff were not providing R1 a physical assist per R1’s Resident Appraisal. A review of documents by Suncrest Home Health revealed that staff were not getting R1 up, and were later provided training to handle R1 by Suncrest Home Health.

In conclusion, the facility did not provide or update a plan to care for R1’s needs. Thus, this allegation was found to be SUBSTANTIATED.

A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where a copy of this report was discussed and provided along with copies of the LIC811, LIC9099D, and Appeal Rights.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 18-AS-20210831170004
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BAYSHIRE RANCHO MIRAGE
FACILITY NUMBER: 331881086
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/09/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2023
Section Cited
CCR
87468.2(a)(4)
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Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition.. in Section 87468.1, Personal Rights of Residents in All Facilities, ...(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency...This requirement was not being met as evidenced by:
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Licensee agrees that they will conduct training with all caregivers to outline their responsibilites in providing care via careplans, and Licensee further agrees to ensure care plans are current. Proof of training will be provided to LPA by POC date
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Based on staff interviews and record review, LPA determined that R1 did not have a plan to provide care for R1's oxygen to ensure that the oxygen did not run out. This poses an immediate health and safety and/or personal rights risk to residents in care.
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Type B
05/23/2023
Section Cited
CCR
87468(a)
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Personal Rights- (a) Residents in residential care facilities for the elderly shall have personal rights...those listed in Sections 87468.1, Personal Rights... and 87468.2, Additional Personal Rights of Residents in Privately Operated Facilities, as applicable to the facility. This requirement was not met as evidenced by:
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Licensee agrees that they will conduct training with all caregivers to outline their responsibilites in responding to resident's button pushes in a timely manner. Proof of training will be provided to LPA by POC date
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Based on LPA interviews and record review, LPA determined that resident call button pushes had delayed responses from staff. This poses a potential personal rights risk to residents 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: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
08/31/2021 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210831170004

FACILITY NAME:BAYSHIRE RANCHO MIRAGEFACILITY NUMBER:
331881086
ADMINISTRATOR:KIRBY, SCOTTFACILITY TYPE:
741
ADDRESS:72201 COUNTRY CLUB DRIVETELEPHONE:
(760) 340-5999
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY:135CENSUS: 104DATE:
05/09/2023
UNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Brittany Holm, AdministratorTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Staff does not ensure that resident's room is clean and sanitary
Staff did not ensure that resident received personal mail
Staff are not adequately trained
Staff mismanaged resident's medications
Facility is overcharging resident for services not required
Staff did not safeguard resident's personal supplies
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPAs) Jesse Gardner and Janette Romero arrived unannounced to deliver findings to an investigation into the allegations listed above. LPAs met with Administrator Brittany Holm and Resident Services Director Michael Maeda explained the purpose of the visit. LPAs later during the tour of the facility.

It was alleged that Resident 1 (R1’s) room was not clean and sanitary, and staff were not ensuring that it was kept clean. Document reveal showed that R1’s room (#135) was scheduled to be cleaned on Thursday’s. LPA went in room’s 135, 102, 220, 229, and in common areas, and did not observe any unkept or unsanitary condition. Additionally, LPA conducted interviews with residents, who did not report issues with their rooms being clean and sanitary. Thus, this allegation was UNSUBSTANTIATED. This allegation was therefore not able to be dismissed.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 18-AS-20210831170004
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BAYSHIRE RANCHO MIRAGE
FACILITY NUMBER: 331881086
VISIT DATE: 05/09/2023
NARRATIVE
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It was alleged that Resident 1 (R1) did not receive their mail. Through interviews conducted with residents, LPA found that mail is kept at the reception desk, and that residents do not have issues receiving their mail. Thus, this allegation was UNSUBSTANTIATED. This allegation was therefore not able to be dismissed.

It was alleged that staff are not adequately trained to transfer and meet resident's healthcare needs. Upon review of training submitted by staff dated June 1, 2021, documents revealed that staff had transfer training covering proper two-person physical transfers. Thus, this allegation was UNSUBSTANTIATED. This allegation was therefore not able to be dismissed.

It was then alleged that R1's medications were not being managed. Upon review of the R1’s medication list and MAR, LPA discovered that R1 was being administered medications as ordered by R1’s physician. All five staff medical technicians who worked at the facility during the allegation no longer work there and were thus unable to be interviewed. Thus, this allegation was UNSUBSTANTIATED. This allegation was therefore not able to be dismissed.

It was alleged that R1 was being charged for meals that were provided to R1 while in their room. Interviews revealed that the facility charges $10 for meals if a resident is not sick but wants a meal delivered to their room. The facility will not charge a $10 service fee if the resident who is requesting delivery is sick. Investigation revealed that; although R1 was charged $10 for meals, it was not clear as to what was communicated to staff as to the reasoning at the time of request. Thus, this allegation was UNSUBSTANTIATED. This allegation was therefore not able to be dismissed.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 18-AS-20210831170004
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BAYSHIRE RANCHO MIRAGE
FACILITY NUMBER: 331881086
VISIT DATE: 05/09/2023
NARRATIVE
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It was alleged that staff does not ensure that R1's personal items were safeguarded. Regarding the alleged missing items, the missing items were allegedly delivered after R1 was admitted. Per R1’s resident appraisal, R1 was noted to have personal items ordered for R1, as well being provided by the facility. A specific count of what was used/not used was not available to be obtained to be reviewed to compare for discrepancies. Thus, this allegation was UNSUBSTANTIATED. This allegation was therefore not able to be dismissed.

A finding of UNSUBSTANTIATED means that 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.

An exit interview was conducted where a copy of this report was discussed with and provided.

SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 05/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7