336408433-4-10-2025-18-AS-KCLS-DFMMJW-20250411093947

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336408433
Report Date: 04/10/2025
Date Signed: 04/10/2025 12:07:53 PM

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
07/27/2021 and conducted by Evaluator Javier Prieto

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20210727164731

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: 40	DATE:	04/10/2025
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Patrick McAdoo-Morton, Executive Director		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident developed unstageable wounds while in care

Neglect/Lack of care and supervision

INVESTIGATION FINDINGS:

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

Allegation #1: Resident Developed Unstageable Wounds While in Care

Licensing Program Analyst (LPA) Javier Prieto conducted an unannounced visit to deliver findings on the listed allegations. LPA met with Patrick McAdoo-Morton and explained the purpose of the visit.

The investigation was conducted by Department staff. The investigation consisted of records review and interviews with relevant parties. The allegations indicates that due to resident 1 (R1) developed unstageable wounds while in care. Interviews conducted and records reviewed disclosed the facility staff followed required protocols, promptly notifying R1’s Primary Care Physician (PCP) and Home Health providers when wounds were identified. On 07/07/2021, R1’s PCP identified a blister on the resident's left heel, for which facility staff provided routine care and bandaging. On 07/19/2021, R1’s Podiatrist observed ulcerations on both heels but found no evidence of eschar and subsequently recommended Home Health intervention.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: 9512480349(323) 981-3968
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025

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

Control Number 18-AS-20210727164731

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: VISTA COVE AT RANCHO MIRAGE	FACILITY NUMBER: 336408433
	VISIT DATE: 04/10/2025

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
26
27
28
29
30
31
32

On 07/23/2021, Home Health staff assessed the wounds as worsening and on 07/24/2021 R1, was sent to the hospital for wound care. Based on the evidence and interviews, there is no substantial confirmation that the unstageable wounds originated solely while R1 was under the facility's care.

Allegation #2: Neglect/Lack of Care and Supervision

The allegation indicates that R1, developed unstageable pressure wounds due to Neglect/Lack of care and supervision. R1 was diagnosed with an unstageable pressure wound on 07/24/2021. Interviews conducted and records review by Department staff revealed that on 07/07/2021, facility med tech staff (S1) notified R1’s PCP about a blister on R1’s left heel, after which staff provided routine care and bandaging. On 07/19/2021, R1’s Podiatrist noted heel ulcerations, which were free of eschar, and recommended Home Health services. On 07/20/2021, the facility administrator contacted R1’s PCP to request a referral for Home Health services. On 07/23/2021, and on 07/24/2021, a Home Health nurse assessed R1’s condition, noting the presence of eschar and classifying the wounds as unstageable. Interviews with a Certified Wound Specialist (S2) indicated that the initial description of the blister was consistent with a Stage II ulcer. The facility staff followed proper protocols, including timely notification of healthcare professionals when Home Health services were deemed necessary.

Based on the information gathered, there is insufficient evidence to substantiate the allegations that R1 developed unstageable wounds or that neglect and lack of supervision occurred. The allegations are Unsubstantiated. A copy of this report was signed by LPA Prieto and Executive Director Patrick McAdoo-Morton . A copy of the report was provided to the administrator.

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: 9512480349(323) 981-3968
LICENSING EVALUATOR NAME: Javier Prieto	TELEPHONE: 951-217-3135
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 2