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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881086
Report Date: 09/25/2023
Date Signed: 09/25/2023 03:12:52 PM


Document Has Been Signed on 09/25/2023 03:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 MIRAGEFACILITY NUMBER:
331881086
ADMINISTRATOR:KIRBY, SCOTTFACILITY TYPE:
741
ADDRESS:72201 COUNTRY CLUB DRIVETELEPHONE:
(760) 340-5999
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY:135CENSUS: 101DATE:
09/25/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Michael Maeda, Resident Services DirectorTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to address a violation observed during the investigation of complaint #18-AS-20221209144911. The LPA met with Resident Services Director (RSD), Michael Maeda, and informed him of the purpose for the visit.

During the complaint investigation the LPA became aware, through interviews and text messages, that a facility manager became aware of an alleged physical and verbal assault involving Resident One (R1) and Staff One (S1). Staff Two (S2), a manager, reported no written or verbal incident report was made to report the incident due to an internal investigation showing the alleged incident could not be corroborated.

Regulatory requirements indicate mandated reporters are to report incidences to appropriate agencies whenever abuse is suspected. S1 reported they initially suspected an abuse did take place, which lead to the internal investigation. Due to the incident not being reported to appropriate agencies a citation will be issued.

An exit interview was conducted; this report was reviewed with Resident Services Director (RSD) Maeda and a copy was provided.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) -24-0313
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/25/2023 03:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2023
Section Cited
CCR
87211(c)

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REPORTING REQUIREMENTS: (c) Any suspected physical abuse that does not result in serious bodily injury of an elder or dependent adult shall be reported to the local ombudsman, the corresponding licensing agency, & the local law enforcement agency within 24 hours as required by 15630(b)(1).
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RSD Maeda stated proof of in-service training, relating to mandated reporting, will provided to all staff by POC due date.
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This requirement was not met, as evidenced by: Based on interviews & text messages, the Licensee didn't ensure the suspected abuse of R1 was reported due to an internal investigation showing the alleged incident could not be corroborated.
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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: Rikesha StampsTELEPHONE: (951) -24-0313
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2023
LIC809 (FAS) - (06/04)
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