Vista Cove at Rancho Mirage

Allegation investigated: 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

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 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.the state’s words, verbatim · CDSS document, Mar 23, 2026 · control 18-AS-20220126152553

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(2) · Plan of correction due date: Apr 22, 2026

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: 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.the state’s words, verbatim · CDSS document, Mar 23, 2026

Plan of correction: 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.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced annual required visit. Upon entry, LPA was greeted by Patrick McAdoo-Morton, Administrator, and informed them of the purpose of the visit. At the time of the visit, there were 14 staff members and 37 residents present. Facility Overview: The facility is 2 unit one story building with (26) bedrooms and (18) bathrooms. There are no pools or known firearms on the premises. Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility has infection control plan in file. Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. The outdoor area was free of hazards. This facility has laundry rooms in each unit. Sharp and dangerous objects were securely locked and inaccessible to residents. LPA reviewed fire marshal's annual inspection report with no deficiencies. The hot water temperature was 115°F. There were 16 fire extinguishers in the facility with current inspection tags. Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods. Continued on LIC809-C..... Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate. Record Review and Resident/Staff Files: LPA reviewed files for five (5) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Five (5) resident files were reviewed and contained all required documentation. Health-Related Services/Incidental Medical Services: All resident medications were securely locked. LPA reviewed medications for five (5) residents, confirming that all medications were listed on the Medication Administration Record (MAR) and accounted for. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 11-05-2025, which met department requirements. All facility exits were clear of obstructions. No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed and provided. LPA left the facility at 12:05 PM and returned at 1:05 PM.the state’s words, verbatim · CDSS document, Nov 21, 2025

Allegation investigated: Staff did not provide adequate supervision resulting in resident being assaulted by another resident

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced subsequent complaint visit to investigate the above listed allegation. The purpose of this visit is to deliver findings for the above listed allegation. Upon arrival at 11:50 a.m., LPA Mosley was greeted by Marketing Coordinator, Angel Ibarra who called the Manager on duty and the Executive Director. LPA met with Residences Services Director Jennifer “Lola” Andrews and Executive Director (ED) Patrick McAoo-Morton and the reason for the visit was explained. Entrance interview conducted. On 06/21/2023, the Department received a complaint regarding the following allegation, Staff did not provide adequate supervision resulting in resident being assaulted by another resident. On 06/27/2023 LPA Venus Mixson conducted the unannounced initial 10-day complaint visit, conducted a physical plant tour and obtained copies of pertinent documents relevant to the investigation. On 06/23/2023 and 7/18/2023 attempts were made to contact the Power of Attorney (POA) of Resident #1 (R1). Report continued on LIC 9099-C PAGE 2... Unsubstantiated (Page 2) Report continued from LIC 9099... During today’s visit, starting at 11:50 a.m. LPA conducted the entrance interview and a brief physical plant tour to ensure there are no immediate health and safety concerns, and facility is in compliance with Title 22 Regulations. At 1:00 p.m., an in-person interview was conducted with the RSD. At 2:10 p.m., an in-person interview was conducted with the ED. At 3:13 p.m., a file review was completed for R1. At 3:25 p.m. and 3:27 p.m., attempts were made to conduct two (2) resident interviews with individuals who resided in the community during June 2023. At 3:30 p.m., one (1) in-person interview was conducted with a resident who resided in the community during June 2023. Additionally, two (2) staff interviews were conducted with employees who were employed during June 2023, at 4:00 p.m. a telephonic interview with POA of R1 was attempted and copies of pertinent documents relevant to the investigation were obtained. On the allegation Staff did not provide adequate supervision resulting in resident being assaulted by another resident, it is the concern of the reporting party (RP) that R1 was assaulted on 06/11/2023 by another resident due to lack of supervision. To investigate this complaint, LPA Mosley conducted in person interviews, attempted to conduct a telephonic interview, a file and record review and obtained copies of pertinent documents relevant to the investigation. File review revealed that R1 was admitted to the facility on respite care from 06/11/2023 to 6/18/2023. R1 was on hospice. R1 did not have any documentation or incident reports related to any incidents while at the facility. Record review revealed that there was no incident report for R1 or for the alleged incident date of 06/11/2023. Interview attempts with the POA of R1 were made on 06/23/2023, 7/18/2023, 11/8/2025 and were unsuccessful. Resident interview revealed that during the time frame of June 2023 they felt safe at the facility. There was adequate supervision. They were not assaulted by another resident. They did not witness or hear of another resident being assaulted by another resident. Staff interviews revealed that during the time frame of June of 2023 they do not recall R1. They do not recall any incidents that took place during June of 2023. During June of 2023 they provided adequate supervision and kept the residents safe. It was noted that residents can get agitated and may attempt to strike another resident, however they are trained to step in and redirect the behavior. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Staff did not provide adequate supervision resulting in resident being assaulted by another resident is deemed unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was provided.the state’s words, verbatim · CDSS document, Nov 8, 2025 · control 18-AS-20230621170419

Allegation investigated: Facility is threatening to evict a resident

Licensing Program Analyst (LPA) Erica Mosley conducted an unannounced subsequent complaint visit to investigate the above listed allegation. The purpose of this visit is to deliver findings for the above listed allegation. Upon arrival at 11:50 a.m., LPA Mosley was greeted by Marketing Coordinator, Angel Ibarra who called the Manager on duty and the Executive Director. LPA met with Residences Services Director Jennifer “Lola” Andrews and Executive Director (ED) Patrick McAoo-Morton and the reason for the visit was explained. Entrance interview conducted. On 09/07/2023, the Department received a complaint regarding the following allegation, Facility is threatening to evict a resident. On 9/11/2023 LPA Yolanda Delgado conducted the unannounced initial 10-day complaint visit, conducted an in-person interview with one (1) staff, and obtained copies of pertinent documents relevant to the investigation. On 9/11/2023 corresponded via email and telephonically with the Spouse of Resident #1 (SR1) and obtained copies of pertinent documents relevant to the investigation. Report continued on LIC 9099-C PAGE 2... Unsubstantiated (Page 2) Report continued from LIC 9099... During today’s visit, starting at 11:50 a.m. LPA conducted the entrance interview and a brief physical plant tour to ensure there are no immediate health and safety concerns, and facility is in compliance with Title 22 Regulations. Starting at 12:40 p.m. LPA Mosley conducted a file review for R1, at 1:00 p.m. conducted an in-person interview with the RSD, at 1:25 p.m. conducted an in-person interview with R1, at 1:42 p.m. attempted to conduct a telephonic phone call with SR1, at 2:10 p.m. conducted an in-person interview with the ED and obtained copies of pertinent documents relevant to the investigation. On the allegation Facility is threatening to evict a resident, it is the concern of the reporting party (RP) that the facility threatened to evict Resident #1 (R1). To investigate this complaint, LPA’s Delgado and Mosley conducted in person interviews, telephonic interviews, file and record review corresponded via email and obtained copies of pertinent documents relevant to the investigation. Interview with the ED at the time revealed that they did not issue an eviction notice to R1. At the time R1 only had one (1) late payment which was on August 31, 2023. R1 received a late payment fee as agreed upon in the admission agreement. It was noted that any resident who pays their rent after the 5th of each month will receive a late fee. Additionally, it was noted that R1 was made aware that if payment was not received an eviction notice would be given after the 30th day. Interview with SR1 revealed that they receive funds through Genworth Financial, a long-term care insurance company that funds R1 to stay at the facility. The insurance company payments do not always arrive on the scheduled payment due date resulting in late payments. It was noted that an agreement was made with the facility to accept the resident based on the payment fluctuations. Interview with R1 revealed that due to their condition they are unable to provide information. Interview with the current ED revealed that R1 is still in the community. R1 has lived in the community since 2020. R1’s invoice is paid regularly, however the dates on when payments are made fluctuate however payments are made within the designated month. Record review revealed that R1 does not have any formal documentation in their file related to an eviction. R1’s statement revealed that on 08/01/2023 R1 had a balance of $6,132.00 that was not paid. On 09/01/2023 R1’s statement balance was $12,214.00. On 09/05/2023 a payment of $6,132.00 was made and on 09/21/2023 the remaining balance of $6,082.00 was made. Although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation of Facility is threatening to evict a resident is deemed unsubstantiated at this time. Exit interview conducted. Report was reviewed and a copy was provided.the state’s words, verbatim · CDSS document, Nov 8, 2025 · control 18-AS-20230907114355

Allegation investigated: Resident developed unstageable wounds while in care Neglect/Lack of care and supervision

Allegation #1: Resident Developed Unstageable Wounds While in Care Licensing Program Analyst (LPA) Javier Prieto conducted an unannounced visit to deliver findings on the listed allegations. LPA met with Patrick McAdoo-Morton and explained the purpose of the visit. The investigation was conducted by Department staff. The investigation consisted of records review and interviews with relevant parties. The allegations indicates that due to resident 1 (R1) developed unstageable wounds while in care. Interviews conducted and records reviewed disclosed the facility staff followed required protocols, promptly notifying R1’s Primary Care Physician (PCP) and Home Health providers when wounds were identified. On 07/07/2021, R1’s PCP identified a blister on the resident's left heel, for which facility staff provided routine care and bandaging. On 07/19/2021, R1’s Podiatrist observed ulcerations on both heels but found no evidence of eschar and subsequently recommended Home Health intervention. Unsubstantiated On 07/23/2021, Home Health staff assessed the wounds as worsening and on 07/24/2021 R1, was sent to the hospital for wound care. Based on the evidence and interviews, there is no substantial confirmation that the unstageable wounds originated solely while R1 was under the facility's care. Allegation #2: Neglect/Lack of Care and Supervision The allegation indicates that R1, developed unstageable pressure wounds due to Neglect/Lack of care and supervision. R1 was diagnosed with an unstageable pressure wound on 07/24/2021. Interviews conducted and records review by Department staff revealed that on 07/07/2021, facility med tech staff (S1) notified R1’s PCP about a blister on R1’s left heel, after which staff provided routine care and bandaging. On 07/19/2021, R1’s Podiatrist noted heel ulcerations, which were free of eschar, and recommended Home Health services. On 07/20/2021, the facility administrator contacted R1’s PCP to request a referral for Home Health services. On 07/23/2021, and on 07/24/2021, a Home Health nurse assessed R1’s condition, noting the presence of eschar and classifying the wounds as unstageable. Interviews with a Certified Wound Specialist (S2) indicated that the initial description of the blister was consistent with a Stage II ulcer. The facility staff followed proper protocols, including timely notification of healthcare professionals when Home Health services were deemed necessary. Based on the information gathered, there is insufficient evidence to substantiate the allegations that R1 developed unstageable wounds or that neglect and lack of supervision occurred. The allegations are Unsubstantiated. A copy of this report was signed by LPA Prieto and Executive Director Patrick McAdoo-Morton . A copy of the report was provided to the administrator.the state’s words, verbatim · CDSS document, Apr 10, 2025 · control 18-AS-20210727164731

Type of visit: Required - 1 Year

On 11/20/2024, Licensing Program Analysts (LPAs), Andrei Castillo and Seo Jeon arrived at the facility unannounced to conduct the required annual inspection. Upon entry, LPAs were greeted by Executive Director, Jack Poyfair and informed him of the purpose of the visit. At the time of the visit, there were ten staff members and forty seven residents present. LPA conducted a tour of the facility with the Executive Director, reviewed facility documents and conducted interviews. The following is a summary of the visit: Facility Overview: The facility has two buildings with total thirty bedrooms and eighteen bathrooms. Resident bedrooms had the required bedding, furniture, and lighting. Facility sketch, exit routes, personal rights, “If you See Something, Say Something,” LTC Ombudsman, complaint information and emergency phone numbers were observed posted in the facility. There was a designated storage space for the residents and staff files, and it was locked and inaccessible to residents in care. Infection Control: There were hand hygiene and hand washing stations, and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements. Physical Plant: Floors, windows, and doors were clean and well-maintained. Furniture and fixtures were in good condition. The outdoor areas were free of hazards and have shaded areas with outdoor furnitures. Laundry equipments were in good working condition. LPA observed fully charged fire extinguishers. Disinfectants, cleaning solutions, and sharp and dangerous objects were securely locked and inaccessible to residents. Cont. LIC 809-C The annual fire extinguisher service maintenance was done on 10/11/2024 by a licensed fire marshal. The hot water temperature was measured at 120°F which is within the required limits. Safety night lights were observed throughout the facility. There were no bodies of water located on the property. According to the Executive Director, there are no firearms or ammunition on the premises. Food Service: The facility’s kitchens were clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods. Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. Administrator’s license is posted in the facility with an expiration date of 10/22/2025. Record Review and Resident/Staff Files: LPA reviewed files for four staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Five resident files were reviewed and contained all required documentation. Health-Related Services/Incidental Medical Services: All resident medications were securely locked. LPA reviewed medications for five residents, confirming that all medications were listed on the Medication Administration Record (MAR) and accounted for. Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, the fire drill was last conducted on 10/11/2024. All facility indoor and outdoor passageways and exits were clear of obstructions and or debris. No deficiencies were found during the visit. An exit interview was conducted, and a copy of this report was reviewed and given to Executive Director, Jack Poyfair..the state’s words, verbatim · CDSS document, Nov 20, 2024

Type of visit: Case Management - Health Checks

Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit for the purpose of conducting a health and safety check. LPA Delgado met with Executive Director Jack Poyfair, explained the nature of the visit and was granted entry into the facility. LPA toured the facility with the ED. The LPA did not observe any health and safety concerns during the visit. An exit interview was conducted where this report was provided to Jack Poyfair.the state’s words, verbatim · CDSS document, Jan 5, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Janira Arreola conducted a required annual visit. LPA was greeted and was granted entry and met with Administrator, Jack Poyfair, who was informed of the purpose of the visit. The facility is a one story building with locked perimeter, approved for (12) hospice and (6) bedridden. No pools or fire arms are kept at the facility. The facility serves elderly residents ages 60 and above. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: Infection Control: LPA observed the hand washing stations with hand hygiene supplies and hand washing signs. The facility has a plan on mitigating infectious diseases and training staff. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. Physical Plant: LPA observed the resident bedrooms and bathrooms. Physical plant, floors, windows, and doors were observed to be clean and fixtures and furniture were present and in good repair. The facility was observed to be free of any hazards. Laundry equipment was observed to be in good repair. The sharp and dangerous objects were observed to be locked and inaccessible to clients. The smoke detector and carbon monoxide was operational, and the hot water temperature read 118.3F. Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods. Record Review and Resident/Staff Files: Two staff files were missing a health screening upon inspection. One staff file was missing current staff training. Deficiencies were cited for these missing files and plan of correction was created with the administrator. Resident files were reviewed and possessed all required paperwork. Health Related Services/ Incidental Medical Services: Resident medication were locked in a medication cart inside a locked medication room. LPA reviewed resident medications for (3) residents and found all medication listed on MARS and all required labeling was found to be in place. Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. LPA reviewed documentation showing last fire drill conducted 11/3/23. Technical advisory note was documented for facility to document required information on future drills. LPA observed all facility exits were clear from obstructions. An exit interview was conducted where a copy of this report, deficiency pages, and appeal rights were provided to Administrator, Jack Poyfair.the state’s words, verbatim · CDSS document, Nov 17, 2023