331881086-6-19-2023-18-AS-SMAZ-CSXUTW-20230619155236

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881086
Report Date: 06/19/2023
Date Signed: 06/19/2023 03:52:44 PM

Document Has Been Signed on 06/19/2023 03:52 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	BAYSHIRE RANCHO MIRAGE		FACILITY NUMBER:	331881086
ADMINISTRATOR:	KIRBY, SCOTT		FACILITY TYPE:	741
ADDRESS:	72201 COUNTRY CLUB DRIVE		TELEPHONE:	(760) 340-5999
CITY:	RANCHO MIRAGE	STATE: CA	ZIP CODE:	92270
CAPACITY:	135	CENSUS: 102	DATE:	06/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Brittany Holm - Administrator		TIME COMPLETED:	04:10 PM

NARRATIVE

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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit. LPA was granted entry and met with Administrator, Brittany Holm, who was informed of the purpose of the visit. At the time of the visit there was (10) staff and (102) residents present.

The facility is a two story building with (121) bedrooms and (128) bathrooms, a pool, and two courtyards. The clients served are elderly adults 65 years of age and up. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted staff and client interviews. LPA observed the following:

Infection Control: The LPA observed the hand washing stations in the facility restrooms and kitchen had hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. LPA reviewed the facility's infection control plan which met department requirements. LPA reviewed staff records and found that all staff had infection control training.

Physical Plant: LPA observed the client bedrooms and staff office. Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed the facility pool was surrounded by a locked gate. LPA observed outdoor furniture and shaded area in the courtyard for residents. The LPA observed sharp and dangerous objects are kept locked in the food storage area. Cleaning supplies and other toxins are kept locked in storage closets. Laundry equipment was observed to be in good working condition. The smoke detector and carbon monoxide was operational, and the hot water temperature 119F.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. LPA was informed the facility receives 4 food deliveries a week.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BAYSHIRE RANCHO MIRAGE	FACILITY NUMBER: 331881086
	VISIT DATE: 06/19/2023

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Care & Supervision/Administration: Adequate staff are present for the supervision of residents during the visit. LPA observed resident # 1 (R1) stuck on the grass making multiple attempts to get back on the sidewalk/path area. R1 was outside in the sun for an unknown amount of time. LPA did not observe any staff during the time and located a staff member to assist R1. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator possesses a current administrator's certificate.

Record Review and Resident/Staff Files: LPA reviewed five (5) staff files and training. LPA observed staff member # 1 (S1) was not associated with the facility a civil penalty will be issued. Four of the five staff have criminal clearance and updated training along with CPR/First Aid Certification. Five (5) resident files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: LPA observed medications are kept locked and inaccessible in the medication room. Medications are labeled. LPA observed multiple MedTechs walking with carts supplying the resident's with their afternoon medication. Medtechs document intake on eMARS. LPA reviewed client medications for (5) resident and found all medication listed on MARS and all required labeling was found to be in place.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing the facility's last fire and earthquake drills, which met the department requirements. LPA observed all facility exits were clear from obstructions. LPA observed emergency supplies and first aid kit with all required items.

An exit interview was conducted where a copy of this report was provided to Administrator, Brittany Holm.

SUPERVISOR'S NAME: Joel Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/19/2023 03:52 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 AC/SC, 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: 06/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Type A

Section Cited

CCR

87464(f)(1)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview the licensee did not comply with the section cited above in providing care and supervision during the LPA's unannounced annual visit. LPA witnessed resident # 1 (R1) outside in the sun making multiple attempts to get out of the sun and onto the walking path for an unknown amount of time which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/20/2023
	Plan of Correction
1 2 3 4	Adminstrator will email LPA statment that they will provide more care and supervision for residents byt the agreed POC date.

Request Denied

Type A

Section Cited

CCR

87355(e)(1)

This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and record review, the licensee did not comply with the section cited above in having staff member # 1 (S1) associated to work at this facility which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/20/2023
	Plan of Correction
1 2 3 4	Administrator will go throught staffing list to ensure every staff working is associated to this facility. S1 will be associated to this facility and proof will be sent to LPA by the POC due date.

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 Esquivel	TELEPHONE: (951) 248-0312
LICENSING EVALUATOR NAME: Sara Martinez	TELEPHONE: (951) 248-0314
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2023

LIC809 (FAS) - (06/04)

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