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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336410691
Report Date: 10/27/2021
Date Signed: 06/02/2023 09:22:20 AM

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
10/21/2021 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211021164216
FACILITY NAME:BROOKDALE MIRAGE INNFACILITY NUMBER:
336410691
ADMINISTRATOR:SPAUN, JOHNFACILITY TYPE:
740
ADDRESS:72750 COUNTRY CLUB DRTELEPHONE:
(760) 346-7772
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY:145CENSUS: 106DATE:
10/27/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Denise Flores, Executive DirectorTIME COMPLETED:
02:50 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff neglect resulted in resident sutaining a pressure injury.
Resident's toileting needs not being met.
Food services are inadequate.
Staff pushed resident while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Jesse Gardner arrived unannounced to the facility to conduct a complaint investigation into the allegations listed above. LPA met with Receptionist Marcy Rios and explained the purpose of the visit. LPA then conducted a tour of the facility.
The investigation consisted of interviews with confidential sources, a review of records, and interviews with staff, and residents.
It was alleged that Resident One (R1) had a bed sore on their left butt cheek, which had not been reported by facility staff. During an interview with a confidential source, it was noted that the abrasion to R1’s buttocks was not a pressure wound. It was deemed shearing that caused friction to sustain an abrasion, but not an open wound. Facility record review indicated that the facility staff was caring for the abrasion. Thus, this allegation was Unsubstantiated.
It was alleged that Resident Two (R2) needs to wait to have assistance with the toilet. Interviews with residents stated that staff are very attentive to their needs, and often check on them in-between button pushes of their pendant. Resident interviews further revealed that staff make the residents feel comfortable when needing assistance in toileting, and mobility. Thus, this allegation was Unsubstantiated.
It was then alleged that Resident Two (R2) needs to wait for staff to serve their food, and to assist them. Record review indicated that R2 needs mobility assistance to and from the dining room and/or community activities as needed. Staff interview revealed that when residents push their call button, each resident is retrieved (who needs assistance) based off of when staff receive the call. When the residents are done eating, the servers will let caregiver staff know and each is prioritized to when they finish eating for retrieval back to their rooms. Interviews with residents stated that staff are punctual in responding to residents who need assistance with getting to/from the dining room. Additionally, LPA observed numerous servers walking throughout the dining hall, and caregivers consistently coming into the dining hall to respond to residents who were done eating to respond to the resident’s needs. Thus, this allegation was Unsubstantiated.
R2 was alleged to have been pushed by a staff member causing them to lose their balance. Interview with staff indicated that when they ask R2 to turn their body to get into their room, sometimes R2 gets confused, and says not to push (assist) him. Staff will encourage R2 to face the caregivers so that R2 knows what is happening as he is assisted so that he does not feel confused in someone pushing him into his room. Thus, this allegation was Unsubstantiated.
A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.
An exit interview was conducted with Executive Director Denise Flores where a copy of this report was discussed and provided.
This is an amended version of this report dated October 27, 2021.

Unsubstantiated
Estimated Days of Completion: 0
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 248-0341
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2023
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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