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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881086
Report Date: 06/10/2024
Date Signed: 06/10/2024 02:42:32 PM


Document Has Been Signed on 06/10/2024 02:42 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: 104DATE:
06/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Executive Director Jimmy StewartTIME COMPLETED:
02:55 PM
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Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit . LPA was granted entry and met with Jimmy Stewart who was informed of the purpose of the visit. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following:

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 a courtyard with outdoor furniture and shaded area for residents. Facility contained PPE equipment and cleaning supplies to do regular cleaning of the facility. Cleaning supplies, detergents, and the sharp and dangerous objects were locked and inaccessible to the residents in the facility's janitorial and maintenance supply rooms. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The smoke detector, carbon monoxide, and facility sprinkler system was operational and is maintained annually. LPA tested the hot water temperature in multiple resident bathrooms which met department requirements. 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 multiple food deliveries a week.



LPA reviewed five (5) staff files and training. All staff have the required personnel records on file and criminal record clearance and updated training along with CPR/First Aid Certification. Five (5) resident files were reviewed, and possessed all required paperwork which included Admissions Agreement, Needs and Service Plan, and Physician's Report. The listed administrator possesses a current administrator's certificate.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BAYSHIRE RANCHO MIRAGE
FACILITY NUMBER: 331881086
VISIT DATE: 06/10/2024
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LPA observed medications are kept locked and inaccessible to residents in the medication room. Medications are labeled. LPA observed a MedTech walking with a medication cart supplying the resident's with their afternoon medication. MedTech documented intake on the facility's electronic Medication Administration Record (eMAR). LPA reviewed client medications for (5) resident and found all medication listed on MARS and all required labeling was found to be in place.

Facility has an updated emergency and disaster plan and Infection Control plan. LPA observed all facility exits were clear from obstructions. Facility has a working delayed egress system on the exit doors in the Memory Care Unit. LPA observed emergency supplies and first aid kit with all required items. Facility contained multiple charged fire extinguishers located throughout the facility. Facility had performed a fire drill during the first week of June 2024 which met department requirements.

No deficiencies were cited at the time of the visit.

An exit interview was conducted where a copy of this report was provided to Executive Director Jimmy Stewart.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Sara MartinezTELEPHONE: (951) 605-0913
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
LIC809 (FAS) - (06/04)
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