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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881086
Report Date: 10/19/2021
Date Signed: 05/09/2023 10:37:13 AM

Unsubstantiated


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
08/31/2021 and conducted by Evaluator Jesse Gardner
COMPLAINT CONTROL NUMBER: 18-AS-20210831085458
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: 77DATE:
10/19/2021
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Roland Gandy, DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not follow CDC guidelines for preventing the spread of COVID-19
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jesse Gardner arrived a the facility and met with Director Roland Gandy. LPA Gardner made Mr. Gandy aware of the above allegation. It was alleged that staff do not wear masks when they enter Resident 1's (R1) room.

In addition to interviews with staff, LPA observed staff practicing COVID-19 measures of temperature taking, and mask wearing for staff members, and also observed visitors getting screened upon entry. LPA Gardner conducted staff and resident interviews, and determined the allegation "Staff did not follow CDC guidelines for preventing the spread of COVID-19" was UNSUBSTANTIATED.

A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. A copy of this report was reviewed with and provided to Mr. Gandy. This is an amended version of the original report dated 10/19/2021.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0341
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
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 2
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
08/31/2021 and conducted by Evaluator Jesse Gardner
COMPLAINT CONTROL NUMBER: 18-AS-20210831085458

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: 77DATE:
10/19/2021
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Roland Gandy, DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff administered COVID vaccine without resident's authorized representatives consent
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jesse Gardner arrived a the facility and met with Director Roland Gandy. LPA Gardner made Mr. Gandy aware of the above allegation.

The allegation was that a vaccine was administered without the authorized representatives consent. Interviews with staff and a pertinent witness, it was determined R1's responsible party did provide consent for R1 to be vaccinated.

Through interviews with staff, this allegation was determined to be UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. A copy of this report was reviewed with and provided to Mr. Gandy.

This is an amended version of the original report dated 10/19/2021.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0341
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2