336410691-4-10-2023-18-AS-KCLS-CRBSMQ-20230428140019

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336410691
Report Date: 04/10/2023
Date Signed: 04/10/2023 02:57:39 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
07/09/2020 and conducted by Evaluator Rayshaun Nickolas

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20200709152202

FACILITY NAME:	BROOKDALE MIRAGE INN		FACILITY NUMBER:	336410691
ADMINISTRATOR:	SPAUN, JOHN		FACILITY TYPE:	740
ADDRESS:	72750 COUNTRY CLUB DR		TELEPHONE:	(760) 346-7772
CITY:	RANCHO MIRAGE	STATE: CA	ZIP CODE:	92270
CAPACITY:	145	CENSUS: 124	DATE:	04/10/2023
		UNANNOUNCED	TIME BEGAN:	09:18 AM
MET WITH:	Denise Flores, Executive Director III		TIME COMPLETED:	03:10 PM

ALLEGATION(S):

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Resident sustained multiple pressure injuries while in care.

INVESTIGATION FINDINGS:

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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.

The allegation alleged that resident #1 (R1) was admitted to the hospital on July 8, 2020. The allegation alleged the client had pressure injuries on their back and right calf. LPA Nickolas’ facility file review revealed that R1 was non-ambulatory, according to R1’s physician’s report. However, facility staff could not find all R1’s medical records because R1 moved out of the facility on July 30, 2020, and their files were archived. 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.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Karen Clemons	TELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Rayshaun Nickolas	TELEPHONE: (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)

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