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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881086
Report Date: 09/25/2023
Date Signed: 09/25/2023 03:17:14 PM

Unsubstantiated


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
12/09/2022 and conducted by Evaluator Stephanie Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20221209144911
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
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Michael Maeda, Resident Services DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff handled resident roughly
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to deliver the findings of the investigation into the above allegation. The LPA me with Michael Maeda, Resident Services Director (RSD), and informed him of the purpose for her visit.

A report was received by the Department alleging Staff One (S1), on December 03, 2022, was rough with Resident One (R1). The investigation included staff/resident interviews, records review, and records collection. It was alleged S1 grabbed a wheelchair, roughly put R1 in it, took the resident's arms and pulled them behind their body, before throwing the resident on their bed and roughly pulling off their clothes to change the resident. R1 was interviewed and did not provide a statement regarding the matter; R1 is diagnosed with a condition which can affect their ability to recall. S1 was interviewed; the staff confirmed an incident did take place involving R1 in which the resident did become aggressive and combative. S1 denied handling R1 in a rough or abusive manner. Interviews were held with witnesses, Staff Two (S2) and Three (S3); one staff reported S1 was rough with R1 during the incident while the other staff reported S1 was not observed to be rough. Both staff
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 782-4807
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 18-AS-20221209144911
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: 09/25/2023
NARRATIVE
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reported they were not in the immediate area the entire time and only observed portions of the incident. Therefore, due to a lack of information, this allegation is deemed UNSUBSTANTIATED at this time.

A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation occurred.

An exit interview was conducted; this report was reviewed with RSD Maeda and a copy was provided, along with the LIC 811.
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
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
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
12/09/2022 and conducted by Evaluator Stephanie Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20221209144911

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: DATE:
09/25/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Michael Maeda, Resident Services DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff spoke inappropriately to resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to deliver the findings of the investigation into the above allegation. The LPA me with Resident Services Director (RSD), Michael Maeda, and informed him of the purpose for the visit.

A report was received by the Department alleging Staff One (S1), on December 03, 2022, spoke to R1 inappropriately. The investigation included staff/resident interviews, records review, and records collection. It was reported S1 made statements to R1 about marrying their son, owning all the son's belongings, and causing the resident to become upset. R1 was interviewed and did not provide a statement regarding the matter; R1 is diagnosed with a condition which can affect their ability to recall. S1 could not be reached to provide a comment regarding the allegation. Staff Two (S2) and Staff Three (S3), who were present for the alleged incident, were interviewed. Staff members reported S1 did speak to R1 inappropriately on or around December 03, 2023. One interview reported S1 made a statement criticizing R1 for not wanting to talk with S1 and claiming to have had sexual interactions with R1's family member. The second interview reported S1 was
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20221209144911
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: 09/25/2023
NARRATIVE
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arguing with R1 and did not make attempts to de-escalate the resident. Therefore, based on interviews, this allegation is deemed SUBSTANTIATED.

A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. This violation poses a potential threat to the personal rights of the resident in care; therefore, a citation will be issued.

An exit interview was conducted; this report was reviewed with RSD, Maeda, and a copy was provided, along with the LIC 811 and instructions on appeal rights.
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
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20221209144911
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: 09/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2023
Section Cited
CCR
87468.1(a)(1)
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Personal Rights of Residents in All Facilities: (a) Residents in all RCFEs shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met, as evidenced by: Based on interview, the licensee did not ensure
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The RSD stated proof of in-service training, relating to resident rights, will be provided to all staff by POC due date.
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R1 was accorded dignity in their personal relationship with S1. It was reported S1 made a statement criticizing R1 for not wanting to talk with S1 and claiming to have had sexual interactions with R1's family member. It was also reported S1 argued with R1 & did not make attempts to de-escalate the resident.
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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
LIC9099 (FAS) - (06/04)
Page: 5 of 5