331881086-12-28-2022-18-AS-DMUN-CN6TS5-20230117135835

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331881086
Report Date: 12/12/2022
Date Signed: 12/28/2022 12:43:20 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/09/2021 and conducted by Evaluator Jesse Gardner

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210909080603

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: 104	DATE:	12/12/2022
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Michael Maeda, Resident Services Director		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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9

Staff did not inform resident's authorized representative of issues concerning resident

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jesse Gardner arrived a the facility and met with Resident Services Director (RSD) Michael Maeda. LPA Gardner made Maeda aware of the above allegation and toured the facility.

It was alleged that R1 had several falls while residing at the facility and R1's Power of Attorney (POA) was not notified of the falls. Through documentation provided by the facility, LPA found that on 11/12/2020, and on 11/28/2020, R1's POA was notified of falls; however, per R1's Admission Record, there were (2) POA's listed as responsible parties. Both POA's should've been notified of R1's falls. Therefore, this complaint was SUBSTANTIATED, and the facility was cited per Title 22.

A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

An exit interview was conducted where a copy of this report was discussed with and provided along with copies of the LIC9099-D, and Appeal Rights.

This is an amended version of the original dated 10/19/2021.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20210909080603

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/12/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/11/2023 Section Cited CCR 87211(a)(1)	1 2 3 4 5 6 7	Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement was not being met as evidenced by:	1 2 3 4 5 6 7	Licensee agrees to provide notification of R1's falls to both POA's and provide proof of such to LPA by POC date.
	8 9 10 11 12 13 14	Based on LPA record review, Licensee did not inform R1's falls to both POA's as listed in R1's Admission Record per Title 22. This is a potential health and safety or personal rights violation.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2022

LIC9099 (FAS) - (06/04)

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