336408433-11-17-2023-18-AS-JARA-CXNVUL-20231117154454

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336408433
Report Date: 11/17/2023
Date Signed: 11/17/2023 03:45:00 PM

Document Has Been Signed on 11/17/2023 03:45 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 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: 50	DATE:	11/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Administrator, Jack Poyfair		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Administrator, Jack Poyfair, who was informed of the purpose of the visit. The facility is a one story building with locked perimeter, approved for (12) hospice and (6) bedridden. No pools or fire arms are kept at the facility. The facility serves elderly residents ages 60 and above. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: Infection Control: LPA observed the hand washing stations with hand hygiene supplies and hand washing signs. The facility has a plan on mitigating infectious diseases and training staff. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. Physical Plant: LPA observed the resident bedrooms and bathrooms. Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility was observed to be free of any hazards. Laundry equipment was observed to be in good repair. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature read 118.3F. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023

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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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
	VISIT DATE: 11/17/2023

NARRATIVE

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Record Review and Resident/Staff Files: Two staff files were missing a health screening upon inspection. One staff file was missing current staff training. Deficiencies were cited for these missing files and plan of correction was created with the administrator. Resident files were reviewed and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: Resident medication were locked in a medication cart inside a locked medication room. LPA reviewed resident medications for (3) residents and found all medication listed on MARS and all required labeling was found to be in place.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing last fire drill conducted 11/3/23. Technical advisory note was documented for facility to document required information on future drills. LPA observed all facility exits were clear from obstructions.

An exit interview was conducted where a copy of this report, deficiency pages, and appeal rights were provided to Administrator, Jack Poyfair.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 11/17/2023 03:45 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: 11/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

(f) All personnel…shall be in good health…Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test…A report shall be made of each screening, signed by the examining physician. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above with (2) staff files which did not have health screening for review. This poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/30/2023
	Plan of Correction
1 2 3 4	The administrator agreed to provide copies of the health screenings for S1 and S2 by the poc due date.

Type B

Section Cited

CCR

87412(c)

87412 Personnel Records (c) Licensees shall maintain in the personnel records verification of required staff training and orientation. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above with S1's full record of training conducted was not able to be reviewed during the time of the visit. This posesa potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/30/2023
	Plan of Correction
1 2 3 4	The administrator agreed to provide the training to the LPA by the POC due date for S1.

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 Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2023

LIC809 (FAS) - (06/04)

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