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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336410691
Report Date: 06/14/2022
Date Signed: 06/14/2022 01:02:27 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
06/08/2022 and conducted by Evaluator Stephanie Torres
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20220608144855
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: 113DATE:
06/14/2022
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Usbaldo Martinez, Executive Director (AD)TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff failed to respond to call system in a timely manner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to initiate the investigation into the above allegation. The LPA met with Executive Director (ED), Usbaldo Martinez, and informed him of the purpose of her visit.

On this date staff/resident interviews were conducted, records were reviewed and copies of pertinent documentation were obtained. Regarding the allegation, "Staff failed to respond to call system in a timely manner," it was alleged Resident One (R1) sustained a fall on or around June 02, 2022, activated their pendant for staff assistance and did not receive a response for thirty minutes. Executive Director (ED) Usbaldo Martinez and Assistant Director (AD), Denise Flores, were interviewed. Flores reported staff are to respond within zero to twenty minutes after the call system is activated. Flores reported she was present for the incident involving R1. She reported R1 sustained a fall on June 03, 2022 and, when staff responded, the resident was refusing assistance. A log of the call system was obtained; the report shows a call was activated for R1 and was responded to within seventeen minutes. R1 was interviewed and reported staff responded within ten to
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
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-20220608144855
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: BROOKDALE MIRAGE INN
FACILITY NUMBER: 336410691
VISIT DATE: 06/14/2022
NARRATIVE
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fifteen minutes. Therefore, based on interviews and records, this allegation is deemed UNSUBSTANTIATED at this time. A finding that the complaint is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove the alleged violation occurred.

This report was reviewed with Martinez and a copy was provided.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2