336410691-4-10-2023-18-AS-KCLS-CRBSKU-20230428135718

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 336410691
Report Date: 04/10/2023
Date Signed: 04/10/2023 02:49:36 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-20201102163741

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:	02:48 PM

ALLEGATION(S):

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Facility staff caused bruising to resident.
Facility staff handled resident in a rough manner.
Facility staff yells at residents.

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.

Allegation #1 “Facility staff caused bruising to resident”. The allegation alleged that staff #1 (S1) grabbed resident # 1 (R1) on the resident’s right forearm, leaving a visible bruise. LPA Nickolas' facility file review revealed that S1 no longer works at the facility, and R1 moved out on January 1, 2022. Therefore, both parties were not interviewed during this investigation. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

Allegation # 2 “Facility staff handled resident in a rough manner”. The allegation alleged that S1 grabbed resident R1. LPA Nickolas’ investigation into this incident revealed that S1 no longer works at the facility, and R1 no moved out of the facility on January 1, 2022. The finding is Unsubstantiated. There is no evidence or witnesses to corroborate the allegation.

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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Control Number 18-AS-20201102163741

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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Allegation # 3” Facility yells at resident”. The allegation alleged that according to the reporting party (RP) interview with the facility’s administrator, the administrator admitted to the RP that R1 had a history of yelling at the residents; however, R1 had no prior incidents of physical abuse. LPA Nickolas' interview with the former administrator revealed that S1 was suspended for yelling at another resident while the facility's investigation was underway. The former administrator stated that this incident occurred before this allegation about R1 was received. However, S1 quit while placed on suspension, and the facility investigation into the incident revealed no evidence that S1 was yelling at that resident. The former administrator stated that I explained this history to the RP when an inquiry about S1 yelling at R1 was made. LPA Nickolas' facility file review revealed that S1 no longer works at the facility, and R1 moved out on January 1, 2022. Therefore, both parties were not interviewed during this investigation. 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 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

LIC9099 (FAS) - (06/04)

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