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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336408433
Report Date: 03/23/2026
Date Signed: 03/23/2026 10:46:48 AM

Unsubstantiated


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
01/26/2022 and conducted by Evaluator Abdoulaye Zerbo
COMPLAINT CONTROL NUMBER: 18-AS-20220126152553
FACILITY NAME:VISTA COVE AT RANCHO MIRAGEFACILITY NUMBER:
336408433
ADMINISTRATOR:JACK POYFAIRFACILITY TYPE:
740
ADDRESS:70201 MIRAGE COVE DRIVETELEPHONE:
(760) 324-4604
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY:68CENSUS: 40DATE:
03/23/2026
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:PATRICK MCADOO-MORTONTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Lack of staff supervision resulted in resident sustaining a broken hip.
Lack of staff supervision resulted in resident sustaining a head laceration.
Lack of supervision resulting in resident being assaulted by another resident.
Staff neglect resulted in resident dehydration.
Residents are not provided activities
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Abdoulaye Zerbo made an unannounced visit to deliver findings for the allegations listed above. LPA met with Executive Director PATRICK MCADOO-MORTON, who was informed of the purpose of the visit.
It was alleged that Lack of staff supervision resulted in resident sustaining a broken hip. Interviews and records establish that R1 fell in a hallway, initially presenting with a head laceration, and later was diagnosed with a comminuted right femoral neck fracture. Staff were in proximity at the time and facilitated medical evaluation for the laceration. No evidence was provided that R1’s care plan required a 1:1 supervision at the time, nor that the lack of supervision caused the fracture.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2026
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 4
Control Number 18-AS-20220126152553
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: VISTA COVE AT RANCHO MIRAGE
FACILITY NUMBER: 336408433
VISIT DATE: 03/23/2026
NARRATIVE
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It was alleged that Lack of staff supervision resulted in resident sustaining a head laceration. Records review and interviews revealed that R1 misjudged a hallway turn, struck a wall corner, fell backward, and sustained a head laceration. Staff were nearby and responded promptly, arranging EMS/ER evaluation.

It was alleged that Lack of supervision resulted in resident being assaulted by another resident. Confidential witness reported a hallway altercation between R1 and R2. Staff intervened immediately and separated the residents. No injuries were reported.
It was alleged that Staff neglect resulted in resident dehydration. Hospital records dated 12/24/2021 revealed that R1 was dehydrated during admission. Facility staff interviews reported frequent checks. However, the investigation did not obtain facility intake/hydration logs, ADL notes, weights/vitals, or care plan hydration parameters to link dehydration to facility neglect.

It was alleged that Residents are not provided activities. Interviews revealed that the facility reported a centrally based activity program appropriate to memory care. The investigation did not obtain activity calendars, attendance logs, or resident interviews demonstrating a lack of activities. In the absence of contrary documentation, the allegation is unsubstantiated.
Based on the information gathered, there is insufficient evidence to support the allegations mentioned above; Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore these allegations is UNSUBSTANTIATED.
An exit interview was conducted with PATRICK MCADOO-MORTON and a copy of this report was provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
01/26/2022 and conducted by Evaluator Abdoulaye Zerbo
COMPLAINT CONTROL NUMBER: 18-AS-20220126152553

FACILITY NAME:VISTA COVE AT RANCHO MIRAGEFACILITY NUMBER:
336408433
ADMINISTRATOR:JACK POYFAIRFACILITY TYPE:
740
ADDRESS:70201 MIRAGE COVE DRIVETELEPHONE:
(760) 324-4604
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY:68CENSUS: 40DATE:
03/23/2026
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:PATRICK MCADOO-MORTONTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility staff failed to respond to residents change in condition.
INVESTIGATION FINDINGS:
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It was alleged that Facility staff failed to respond to resident’s change in condition. Following the hospital discharge and return to the facility, R1 was unsteady and had leg pain. An interview with the facility’s representative revealed that they did not conduct a full body assessment, focusing on the head laceration. Later that day, RP/POA observed right foot external rotation, hip swelling/bruising, and severe pain, after which the facility called EMS and a right femoral neck fracture was confirmed at the emergency department. The evidence supports that the facility did not adequately assess and timely respond to R1’s change in condition post fall/ER visit, resulting in delayed identification of a serious injury.
Based on record review and interviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code. An exit interview was conducted, and a copy of this report and the 9099-D was provided to PATRICK MCADOO-MORTON
An exit interview was conducted with PATRICK MCADOO-MORTON and a copy of this report, the LIC9099D and appeal rights were provided. will be provided for the cited deficiency.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 18-AS-20220126152553
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: VISTA COVE AT RANCHO MIRAGE
FACILITY NUMBER: 336408433
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/23/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/22/2026
Section Cited
CCR
87465(a)(2)
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87465 :Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility… (2)The licensee shall provide assistance in meeting necessary medical and dental needs…
This requirement was not met, as evidenced by:
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the licensee agrees to implement a standardized Post Fall and Change in Condition Assessment Protocol, which includes:
Full body assessment,
Evaluation of pain, mobility, and ability to bear weight, Vital signs.
Licensee also agreed to conduct training of all care staff and medication technicians on Change in condition recognition.
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Based on records review and interviews, R1 returned from the emergency department after a fall with a head laceration, was noted by staff to be unsteady and reporting leg pain, yet staff did not conduct a full post fall assessment to evaluate for additional injuries.
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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: Anthony Perez
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 03/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4