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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881086
Report Date: 04/05/2024
Date Signed: 04/05/2024 10:43:07 AM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
04/03/2024 and conducted by Evaluator Kathleen Banrasavong
COMPLAINT CONTROL NUMBER: 18-AS-20240403150931
FACILITY NAME:BAYSHIRE RANCHO MIRAGEFACILITY NUMBER:
331881086
ADMINISTRATOR:KIRBY, SCOTTFACILITY TYPE:
741
ADDRESS:72201 COUNTRY CLUB DRIVETELEPHONE:
(760) 340-5999
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY:135CENSUS: 104DATE:
04/05/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator in Training, Rob McFarlaneTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff do not assist resident with transfers.
Facility staff are not meeting resident's care needs.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA), Kathleen Banrasavong, conducted an unannounced visit to the facility to initiate the investigation into the allegation(s) listed above. The LPA met with the Administrator in Training, Rob McFarlane and informed him of the purpose of the LPA’s visit.
The LPA conducted a tour of the interior/exterior areas of the facility, conducted a review of records, obtained, and requested copies of pertinent documentation. The Administrator in Training, Rob McFarlane provided the LPA with the roster for the facility. A review of the resident roster and face sheet indicted that the resident has only been admitted to the Skilled Nursing Facility (SNF). Department of Social Service, Community Care Licensing (CCL) does not have jurisdiction over the SNF. Therefore, this complaint is unfounded. A cross report will be made to the appropriate departments who have jurisdiction. This agency has investigated the complaint alleging, Facility staff do not assist resident with transfers and Facility staff are not meeting resident's care needs. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. An exit interview was conducted, and a copy of this report was provided to the Administrator in Training, Rob McFarlane, as evidenced by his signature.
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
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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