331881086-6-2-2021-18-AS-STOS-C3KVBT-20210601161805

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331881086
Report Date: 06/01/2021
Date Signed: 06/02/2021 08:13:17 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	BAYSHIRE RANCHO MIRAGE		FACILITY NUMBER:	331881086
ADMINISTRATOR:	GANDY, ROLAND		FACILITY TYPE:	741
ADDRESS:	72201 COUNTRY CLUB DRIVE		TELEPHONE:	(760) 340-5999
CITY:	RANCHO MIRAGE	STATE: CA	ZIP CODE:	92270
CAPACITY:	135	CENSUS: 70	DATE:	06/01/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Roland Gandy, Administrator		TIME COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Stephanie Torres, conducted a visit at the facility to conduct an announced pre-licensing inspection. The LPA met with Licensee, Scott Kirby, and Executive Director (ED), Roland Gandy. Application: The application is for a Residential Care Facility for the Elderly (RCFE). The fire clearance has been granted for one hundred and thirty five (135) non-ambulatory residents, of which fifteen (15) may be bedridden. Buildings and Grounds: The interior/exterior walkways of the property were observed to be clutter free with no obstructions present. Smoke and Carbon Monoxide detectors were operable. There are no pools or other bodies of water located at the facility. According to Gandy, there are no weapons stored at the facility. Rooms, furniture, beds, mattresses are all in good repair. The bedrooms are furnished and privacy is available. The dining and leisure areas are clutter free and in good condition. Bathrooms were observed to have non-slip flooring available. The hot water was measured throughout the facility; measurements were 108.3, 108.5, and 108.9 degrees Fahrenheit, which is within regulatory limits. Outdoor areas had sufficient room for activities and leisure. Washing machines and dryers were available and in working order. Storage and Supplies: Activities were observed to be available and in sufficient amount for the requested census. Medications will be stored inaccessible to any unauthorized individuals. Secured areas are available for facility files and resident files. Several first aid kits was observed to be available and complete. Cleaning supplies will be stored away in a locked utility room. Linens and equipment are all in good repair and sufficient for approved census. Fire extinguishers were observed to be available throughout the facility and were fully charged. Food Service: Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021

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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BAYSHIRE RANCHO MIRAGE	FACILITY NUMBER: 331881086
	VISIT DATE: 06/01/2021

NARRATIVE

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are in working order. Sharps will be stored inaccessible to dementia care resident.

Forms: The following signs were observed to be posted: Emergency Disaster Plan (LIC 610E), Theft and Loss Policies, Visitors Policy, Personal Rights, and Facility Sketch (LIC 999), Labor Law Information, and the Complaint Information.

The LPA will inform the Centralized Applications Bureau (CAB) the facility is ready for licensure. This report was discussed with and a copy provided to Gandy.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 06/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/01/2021

LIC809 (FAS) - (06/04)

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