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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881366
Report Date: 02/28/2024
Date Signed: 02/28/2024 02:11:39 PM


Document Has Been Signed on 02/28/2024 02:11 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:RANCHO MIRAGE SENIOR LIVINGFACILITY NUMBER:
331881366
ADMINISTRATOR:KHAY, CHETFACILITY TYPE:
740
ADDRESS:5 SHASTA LAKE DRIVETELEPHONE:
(760) 464-0882
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY:6CENSUS: 5DATE:
02/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Heather Acosta - Facility ManagerTIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting the annual inspection. LPA Colvin met with Facility Manager Heather Acosta and informed her of the purpose of today's inspection. Below is a summary of what was observed:

Infection Control: LPA Colvin observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents. Such measures include: soap and paper towels at hand washing stations, hand washing guides posted, and tight-fitting lids on trash cans.

Physical Plant: LPA Colvin toured the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. LPA Colvin observed the required furniture and linen to be present and in good condition in resident bedrooms. LPA Colvin measured the hot water in the bathroom faucets to be 109.2 degrees. LPA Colvin tested the facility's carbon monoxide alarm and smoke detectors and found them to be operational. LPA Colvin observed that sharp objects like knives were locked away from residents' reach. LPA Colvin observed Lysol toilet bowl cleaner in the staff bathroom which was unlocked and accessible to residents. Deficiency cited. LPA Colvin toured the backyard and confirmed that no exits or pathways were blocked and the facility's swimming pool was fenced off and secured from unauthorized used. LPA Colvin observed sufficient supply of perishable and non-perishable food and utensils and dishes for the residents in care. LPA Colvin observed resident medications in the refrigerator in the garage. The refrigerator was not locked and the door from the facility to the garage was unlocked and open during today's inspection. Deficiency cited.

Operational Requirements: LPA Colvin observed the facility to be operating within their licensed capacity of 6 non-ambulatory residents, one of which may be bedridden. Facility has a hospice waiver for 6 residents.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
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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Document Has Been Signed on 02/28/2024 02:11 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: RANCHO MIRAGE SENIOR LIVING
FACILITY NUMBER: 331881366

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above with one chemical (lysol bathroom cleaner in the staff bathroom) which poses an immediate health and safety risk to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
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Facility Manager states that she will conduct a walk-through of the facility to ensure no other chemicals are accessible. Facility Manager will also conduct a meeting with staff to remind them to lock up chemicals after use. Facility Manager to provide LPA Colvin with roster from staff meeting as well as self-certification that walkthrough was completed by Plan of Correction date of 2/29/24.
Type A
Section Cited
CCR
87355(e)(3)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 4 staff present (O1) which poses an immediate safety risk to persons in care.
POC Due Date: 02/29/2024
Plan of Correction
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New Applicant/Owner Garrette Peterson agrees to leave the premesis and not return until their criminal background clearance has been completed and they are associated to the facility. Self-certification to be submitted to LPA Colvin by Plan of Correction date of 2/29/24.
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: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/28/2024 02:11 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: RANCHO MIRAGE SENIOR LIVING
FACILITY NUMBER: 331881366

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)(11)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (11) A health screening as specified in Section 87411, Personnel Requirements - General.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 2 of 3 staff members (S1 & S2) which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/13/2024
Plan of Correction
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Facility Manager states that they will obtain Health Screening Reports for S1 & S2 and review facility staff files to ensure no other staff are missing these records. Copies of the Health Screening Reports to be submitted to LPA Colvin by Plan of Correction date of 3/13/24.
Type B
Section Cited
CCR
87613(a)(2)
General Requirements for Restricted Health Conditions
(2) Ensure that facility staff who will participate in meeting the resident's specialized care needs complete training provided by a licensed professional sufficient to meet those needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 of 3 staff files reviewed (S1, S2, & Facility Manager), which poses/posed a potential health risk to persons in care. LPA Colvin observed that R1 has Diabetes, but no staff have have training on caring for residents with Diabetes.
POC Due Date: 03/13/2024
Plan of Correction
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Facility Manager agrees to have all staff trained on Diabetes and provide proof of training to LPA Colvin by Plan of Correction date of 3/13/24.
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: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/28/2024 02:11 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: RANCHO MIRAGE SENIOR LIVING
FACILITY NUMBER: 331881366

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(a)
Planned Activities
(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews with staff and residents, the licensee did not comply with the section cited above, which poses/posed a potential personal rights risk to persons in care.
POC Due Date: 03/13/2024
Plan of Correction
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Facility Manager states that they will come up with a list of planned activites for the residents and create a scheudle for when these activites will be offered to residents. Activites should include group activites to foster socialization. Schedule to be provided to LPA Colvin by 3/13/24.
Type B
Section Cited
CCR
87506(a)
Basic Services
Resident Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 of 5 resident files (R3) which poses a potential health risk to persons in care. LPA Colvin observed that R3's Needs & Services Plan is incomplete, listing "See LIC602" for all areas and with no mention of who will provide for each need and how.
POC Due Date: 03/13/2024
Plan of Correction
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Facility Manager agrees to complete an updated Needs and Services Plan for R3, which will be thurough and complete. A copy of the new Plan shall be submitted to LPA Colvin by the Plan of Correction date of 3/13/24.
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: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/28/2024 02:11 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: RANCHO MIRAGE SENIOR LIVING
FACILITY NUMBER: 331881366

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above, which poses a potentia safety risk to persons in care. LPA Colvin interviewed staff, who stated that they have not completed disaster drills at the facility.
POC Due Date: 03/13/2024
Plan of Correction
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Facility Manager agrees to complete a Disaster Drill with staff and residents and maintain a record of the drill in a file at the facility. Facility Manager will create a tentative schedule for quarterly diaster drills. Proof of disaster drill and tentative schedule for future drills to be provided to LPA Colvin by Plan of Correction date of 3/13/24.
Type B
Section Cited
CCR
87109(b)
Transferability of License: (b) The licensee shall notify the licensing agency…in writing…in all cases at least thirty (30) days prior to the transfer of...business, or at the time that a bona fide offer is made, whichever period is longer..

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview, the licensee did not comply with the section cited above, which poses a potential health, safety or personal rights risk to persons in care. LPA Colvin confirmed in interviews with current Licensee and prospective Licensee that the copmany which holds the facility license was sold last month and the Department was not notified.
POC Due Date: 03/13/2024
Plan of Correction
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Facility Manager agrees to have the Licensee submit a notice to the Department in writing of pending change of ownership. Notice to be submitted to LPA Colvin by Plan of Correction date of 3/13/24.
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: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
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: RANCHO MIRAGE SENIOR LIVING
FACILITY NUMBER: 331881366
VISIT DATE: 02/28/2024
NARRATIVE
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Staffing & Staff Records: LPA Colvin confirmed that there are sufficient staff present to meet the needs of residents. LPA Colvin additionally confirmed that the facility has an Administrator with a current Administrator Certificate. LPA Colvin reviewed staff training records, which were electronic, and observed that there was no staff training for diabetes, and LPA Colvin observed that the facility retains a resident (Resident 1), who has Diabetes. Deficiency cited. LPA Colvin did not observe CPR/First Aid Certification Training in one staff member's (S1) file. During the inspection, LPA Colvin was provided with S1's Certification, which LPA Colvin observed to be dated as today's date (2/28/24). LPA Colvin inquired about this and confirmed that staff re-certified while LPA Colvin was at the facility, and stated that their prior certification expired on 2/13/24. LPA Colvin is issuing a Technical Violation instead of a deficiency as S1 does have current CPR/First Aid Certification as of the completion of this report. LPA Colvin additionally observed that 2 of 3 staff files reviewed (Staff 1 & 2) did not contain a Health Clearance Report. Deficiency cited. At today's inspection, LPA Colvin was made aware that the corporation that operates the facility has been sold, and that no notification was made to the Department. Deficiency cited. Additionally, the new potential owner/applicant has been present in the facility for a week (since 2/23/24), training and acting as an Assistant Administrator, but does not have criminal record clearance associated to this facility. Deficiency cited. When a facility has staff present who do not have a criminal background clearance transferred to the facility, a civil penalty of $100 a day for every day the person is at the facility is assessed. LPA Colvin will be assessing a $500 civil penalty ($100 a day for 5 days), which is the maximum that can be assessed unless the violation is repeated.

Resident Records: LPA Colvin reviewed the files for all 5 current residents to confirm that they have the required information present in their files, including Physician's Report, Admissions Agreement, and current Needs & Services Plan. LPA Colvin observed that Resident 2 (R2) is diagnosed with Dementia and their most recent Physician's Report is dated 12/16/22. Residents with Dementia need to have a Physician's Report updated annually. Deficiency cited. LPA Colvin additionally observed that Resident 3 (R3) has a Needs & Services Plan which is incomplete (areas just list "See 602" with no additional information). Deficiency cited. LPA Colvin confirmed that all residents have Admissions Agreements in their file, though LPA Colvin observed that some were for "Wine Country Living", which according to Facility Manager Heather Acosta, was a prior license associated to this location. LPA Colvin will be issuing a Technical Advisory Note as it is best practice to have a completed Admissions Agreement for the current license, even if the resident is already living at the location when ownership is changed.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
LIC809 (FAS) - (06/04)
Page: 6 of 10
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: RANCHO MIRAGE SENIOR LIVING
FACILITY NUMBER: 331881366
VISIT DATE: 02/28/2024
NARRATIVE
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Incidental Medical Services: LPA Colvin observed that resident medication is locked in the hallway and inaccessible to residents. LPA Colvin confirmed that the facility is not retaining any residents with prohibited health conditions. LPA Colvin observed that R1's most recent Physician's Report contains an order for glucose checks to be conducted at breakfast and before bed, and additionally notes that R1 is unable to do their own testing. Interviews with staff reveal that staff do not assist with any glucose testing for R1. Deficiency cited.

Planned Activities: Interviews conducted by LPA Colvin with residents and staff indicate that there are no planned activities which are offered to the resident, though the facility has puzzles available for residents to use. Deficiency cited.

Emergency Disaster Preparedness: LPA Colvin confirmed that the facility has an Emergency Disaster Plan on file, though according to staff, no disaster drills are conducted. Deficiency cited.

An exit interview was conducted with Facility Manager Heather Acosta and a copy of this report, LIC809D, LIC9102-TV, LIC9102-TA, LIC421BG, and appeal rights were provided.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:

DATE: 02/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2024
LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 02/28/2024 02:11 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: RANCHO MIRAGE SENIOR LIVING
FACILITY NUMBER: 331881366

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87464(d)
Basic Services :(d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs as identified in the pre-admission appraisal specified in Section 87457, Pre-admission Appraisal and providing the other basic services specified below, either directly or through outside resources.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above in 1 of 5 residents (R1), which poses an immediate health risk to persons in care. LPA Colvin observed that R1's most recent Physican's Report has an order for glucose testing twice daily, which staff state they are not assisting with,
POC Due Date: 02/29/2024
Plan of Correction
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Facility Manager claims that R1's doctor has discontinued the order as of today's date. Facility Manager to provde LPA Colvin with copy of the new order as well as self-certification that all resident files have been reviewed to ensure accuracy and no unmet needs. Copy of the new order and self-certification due by Plan of Correction date of 2/29/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Crystal ColvinTELEPHONE: (951) 204-0848
LICENSING EVALUATOR SIGNATURE:
DATE: 02/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/28/2024
LIC809 (FAS) - (06/04)
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