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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408433
Report Date: 07/27/2023
Date Signed: 07/27/2023 04:53:30 PM


Document Has Been Signed on 07/27/2023 04:53 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:VISTA COVE AT RANCHO MIRAGEFACILITY NUMBER:
336408433
ADMINISTRATOR:JACK POYFAIRFACILITY TYPE:
740
ADDRESS:70201 MIRAGE COVE DRIVETELEPHONE:
(760) 324-4604
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY:68CENSUS: 51DATE:
07/27/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jack Poyfair, AdministratorTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Martinez, conducted an unannounced visit to the facility to address a violation observed during the investigation of complaints #18-AS-20230724152734. The LPA met with Jack Poyfair, Administrator, and informed him of the purpose for her visit.

The LPA observed Staff One (S1) and Staff Two (S2) to be working with residents and on the premises without a proper background check clearance. Both staff are pending a fingerprint clearance. This poses an immediate risk to the health, safety and personal rights of the residents in care. A citation and civil penalty will be issued.

An exit interview was conducted; this report was reviewed with Poyfair and a copy was provided, along with information on appeal rights.
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 07/27/2023 04:53 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: VISTA COVE AT RANCHO MIRAGE
FACILITY NUMBER: 336408433

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/27/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/28/2023
Section Cited
CCR
87355(e)(1)

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CRIMINAL RECORD CLEARANCE: All individuals subject to a criminal record review pursuant to H&S Code.. .1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Obtain a California clearance or a criminal record exemption as required by the Department. This requirement was
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The Administrator stated a policy will be established to ensure individuals do not work or are present on the premises until a clearance is received. He stated the policy will provided by POC due date.
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not met, as evidenced by: Based on observation, the Licensee did not ensure staff were fingerprint cleared prior to working in the facility.
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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: Jazmond D HarrisTELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 07/27/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/27/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2