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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331881086
Report Date: 10/18/2025
Date Signed: 10/18/2025 02:45:37 PM

Substantiated


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
12/28/2022 and conducted by Evaluator Cynthia D Chan
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20221228121355
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: 107DATE:
10/18/2025
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Valentina Murrell, Assistant Resident Services DirectorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Lack of supervision resulted in resident eloping from the facility.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit to deliver findings for the allegation listed above. LPA met with the Assistant Resident Services Director, Valentina Murrell, and explained the reason for the visit.

The investigation consisted of the following:
On 12/30/22, LPA Stephanie Torres conducted the initial investigation and interviewed staff and resident, reviewed records, and obtained copies of pertinent documentation. On 7/8/24, LPA Kathleen Banrasavong made a follow-up visit and requested additional documents. During the visit today, LPA Chan interviewed three (3) staff and three (3) residents.

(Continue on LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2025
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-20221228121355
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: BAYSHIRE RANCHO MIRAGE
FACILITY NUMBER: 331881086
VISIT DATE: 10/18/2025
NARRATIVE
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The investigation revealed the following:

Allegation - Lack of supervision resulted in the resident eloping from the facility. It was alleged that Resident #1 (R1) had 6 elopements in 2022 while residing at the facility. Based on information gathered, R1 had eloped from the facility at least twice on different occasions. Therefore, this allegation is deemed substantiated. LPA Stephanie Torres interviewed four (4) staff in 2022, and all stated that R1 had eloped at least once from the facility. In addition, LPA Torres interviewed R1 who provided the details on how the resident eloped on one of the occasions from the facility.

LPA Cynthia Chan obtained and reviewed documents on R1. R1 was admitted to the facility on 8/19/22. The physician’s report stated that R1 is unable to leave the facility unassisted. The facility provided an incident report for R1’s elopement on 10/16/22, which noted that R1 eloped from the west side door of the memory care unit. LPA interviewed three (3) staff during the visit today. Staff stated that some residents will attempt to exit through the delayed egress doors, but when staff hear the alarm, they will quickly get to the exit and redirect the residents away from the door. Staff stated they are always supervising residents to ensure their safety. The three (3) residents interviewed today stated the staff are always present and assisting them with their needs. One of the resident stated that when the exit door alarms go off, the staff will rush to the door and bring back the resident.

Based on LPAs interviews conducted and record review, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D.



An exit interview was conducted. The Plan of Correction was reviewed and developed with the Executive Director, Jimmy Stewart, via telephone. A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20221228121355
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BAYSHIRE RANCHO MIRAGE
FACILITY NUMBER: 331881086
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/19/2025
Section Cited
CCR
87411(a)
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87411 Personnel Requirements – General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.
This requirement is not met as evidenced by:
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Licensee shall provide a plan to ensure staff are supervising residents to avoid any elopements in the memory care unit. An in-service training will be given to staff in the upcoming week. The POC shall be submitted to LPA by 10/19/25.
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Based on record review and interviews, R1 eloped at least once from the memory care unit which poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2025
LIC9099 (FAS) - (06/04)
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