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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336410691
Report Date: 04/10/2023
Date Signed: 04/10/2023 02:39:45 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/02/2020 and conducted by Evaluator Rayshaun Nickolas
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20201102093836
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: 124DATE:
04/10/2023
UNANNOUNCEDTIME BEGAN:
09:18 AM
MET WITH:Denise Flores, Executive Director IIITIME COMPLETED:
02:38 PM
ALLEGATION(S):
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9
Resident sustained a pressure injury while in care.
Licensee did not ensure changes of resident's condition were reported to a physician in a timely manner.
Licensee did not answer communications promptly and appropriately to the resident's representative.
Licensee did not follow facility policy concerning refunds.
Resident was charged for services not received.
Staff did not meet resident's showering needs.

INVESTIGATION FINDINGS:
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2
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Licensing Program Analyst (LPA) Rayshaun Nickolas visited the facility unannounced to deliver the finding on the above allegations. LPA met with Executive Director III Denise Flores and explained the purpose of the visit. The investigation consisted of file reviews and interviews with relevant parties.

Allegation #1 “Resident sustained a pressure injury while in care”. The allegation alleged that On August 9, 2020, resident # 1 (R1) with bedsore. The reporting party (RP) stated that the stage of the bedsore is unknown. LPA Nickolas’ facility file review revealed that the facility communicated with R1’s physician throughout their stay there. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation # 2 “Licensee did not ensure changes of resident's condition were reported to a physician in a timely manner”. The allegation alleged that an unknown nurse from the facility’s corporate offices visited, saw R1, and immediately sent R1 to the hospital. The allegation alleged that the RP spoke with facility staff that day and was advised that R1 was doing well.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: (951) 255-9516
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
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 3
Control Number 18-AS-20201102093836
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: BROOKDALE MIRAGE INN
FACILITY NUMBER: 336410691
VISIT DATE: 04/10/2023
NARRATIVE
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LPA Nickolas’ facility file review revealed that on August 9, 2020, the facility notified R1’s physician of changes in R1’s condition. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation # 3” Licensee did not answer communications promptly and appropriately to the resident's representative”. The allegation alleged that between March and August, the RP called the facility frequently to check on the resident, and the facility staff stated that R1 was doing well. The allegation alleged that an unknown nurse from the facility’s corporate offices visited, saw R1, and immediately sent R1 to the hospital. The allegation alleged that the RP spoke with facility staff that day and was advised that R1 was doing well. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation #4 “Licensee did not follow facility policy concerning refunds”. The allegation alleged that the facility’s former administrator told the RP that they would refund R1’s money paid through the end of September. The allegation alleged that at the point this allegation was received by Community Care Licensing Division (CCLD), the facility owed the resident $4,000. LPA Nickolas’ interview with Executive Director III revealed that R1 was a resident at the facility from March 7, 2020-September 26, 2020. LPA Nickolas’ review of R1’s “Account History Report” revealed that the facility refunded R1 $1,843.87. This refund included care credit and basic service rate. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation #5 “Resident was charged for services not received”. The allegation alleged that R1 was initially supposed to receive two (2) showers weekly. In April, R1’s showers increased from twice a week to daily, and the facility started charging an additional month each month for the shower increase. The allegation alleged that while moving R1 out of the facility, the RP discovered a sign on the wall instructing caregivers to shower the resident only two (2) times a week. LPA Nickolas’ interview with Executive Director III revealed that caregivers follow the facility's "personal service plan," not a sign on the wall. LPA Nickolas' review of R1's "Account History Report" revealed that R1 was refunded $994.00 in care credit. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation # 6 “Staff did not meet resident's showering needs.” The allegation alleged that R1 was initially supposed to receive two (2) showers weekly. In April, R1’s showers increased from twice a week to daily, and the facility started charging an additional month each month for the shower increase.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: (951) 255-9516
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20201102093836
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
Lookup Error,
, CA
FACILITY NAME: BROOKDALE MIRAGE INN
FACILITY NUMBER: 336410691
VISIT DATE: 04/10/2023
NARRATIVE
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The allegation alleged that while moving R1 out of the facility, the RP discovered a sign on the wall instructing caregivers to shower the resident only two (2) times a week. LPA Nickolas’ interview with Executive Director III revealed that caregivers follow the facility's "personal service plan," not a sign on the wall. LPA Nickolas’ file review revealed that R1’s "personal service plan" was updated to daily showers on June 28, 2020, not April 2020. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

A finding of Unsubstantiated means 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 and copy of this report was provided.
SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Rayshaun NickolasTELEPHONE: (951) 255-9516
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3