336408433-7-7-2021-18-AS-NBRN-C4WN8W-20210714101459

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336408433
Report Date: 03/18/2021
Date Signed: 07/07/2021 04:40:28 PM

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 MS29-26
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/11/2021 and conducted by Evaluator Shaunte Henry

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210311121526

FACILITY NAME:	VISTA COVE AT RANCHO MIRAGE		FACILITY NUMBER:	336408433
ADMINISTRATOR:	JACK POYFAIR		FACILITY TYPE:	740
ADDRESS:	70201 MIRAGE COVE DRIVE		TELEPHONE:	(760) 324-4604
CITY:	RANCHO MIRAGE	STATE: CA	ZIP CODE:	92270
CAPACITY:	68	CENSUS: 68	DATE:	03/18/2021
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Jack Poyfair, Executive Director		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident illegally evicted from the facility

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 3/18/21 Licensing Program Analyst (LPA) Shaunte Henry conducted a tele-visit via Duo due to COVID-19 to investigate the above allegation. LPA met with Executive Director (ED) Jack Poyfair and explained the elements of the complaint.

The investigation consisted of interviews and document review. Resident 1 (R1) sustained an injury on 3/9/21, was admitted to the hospital and had surgery. Upon discharge from the hospital, R1 was transferred to a skilled nursing facility for rehabilitation, therefore the faciltiy did not illegally evict R1.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED at this time. An exit interview was conducted where this report and LIC 811 were discussed with and provided to the ED via email.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Shaunte Henry	TELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

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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