Bayshire Rancho Mirage

Type of visit: Required - 1 Year

On 07/03/2026 Licensing Program Analyst (LPA) Aziz Faizi conducted an unannounced annual required visit. Upon entry, LPA was greeted by Michael Maeda, Resident Service Director (RSD), and was informed of the purpose of the visit. The facility is a two-story home with 113 bedrooms, and each bedroom includes its own private bathroom.There are no known firearms on the premises. LPA toured the facility's exterior and observed outdoor pathways were free of obstructions. Outdoor shaded seating area is available for the clients in care. Facility also includes a fitness center, a library, and a game room. The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. LPA toured the kitchen and observed the facility has a two-day supply of perishable foods and more than a seven-day supply of non-perishable foods, which are stored in a safe and healthy manner. LPA observed laundry equipment was in good shape. Sharp and dangerous objects were securely locked and inaccessible to residents. Both the smoke detector and carbon monoxide detector were operational, and the hot water temperature was 108.6°F. Fire extinguishers equipped throughout the building are maintained in accordance with the department's safety requirements expiring on 06/04/2027. Continued with 809C... Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate expiring on 10/7/2026. LPA reviewed files for eight (8) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Eight (8) resident files were reviewed and contained all required documentation. All resident medications were securely locked in carts. LPA observed medications were checked and listed ensuring accuracy and proper documentation by the facility and staff. LPAs reviewed the facility’s emergency and disaster plan, including documentation of the last fire/earthquake drill conducted on 06/08/2026, 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.the state’s words, verbatim · CDSS document, Jul 3, 2026

Allegation investigated: Staff did not provide adequate meals to residents in care Residents are not provided sufficient activities Staff did not update resident's care plan Staff did not provide timely assistance to resident in care

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegations. LPA met with Michael Maeda, Resident Service Director and informed them of the purpose of the visit. The Department’s investigation involved interviews with staff and residents and review of records. On February 4, 2025, Community Care Licensing (The Department) received a complaint report with the following allegations. It was alleged that staff did not provide adequate meals to residents in care. Information received indicated that quality of facility food served has gone down with the current food service manager. LPA conducted interviews with nine (9) residents. Five (5) residents interviewed stated that the food service has been good. Four (4) residents interviewed stated that the food service has been about average. Continued on LIC9099-C.... Unsubstantiated Two (2) of the residents interviewed were involved in the facility resident council and stated that the facility management was in the process of hiring a new food service manager. Based on the interviews conducted, the Department’s investigation did not provide enough information to corroborate the allegation that staff did not provide adequate meals to residents in care. This allegation is unsubstantiated. It was alleged that residents are not provided sufficient activities. Information received indicated that the facility currently offer only one (1) or two (2) activities per day. LPA conducted a tour of the facility and observed a monthly activities calendar posted at the reception area. The activities calendar showed five (5) to six (6) activities per day, 7 days a week. LPA conducted interviews with nine (9) residents, all of whom confirmed the number of activities provided for the residents in care. LPA conducted an interview with the activities director who also confirmed the number of activities. This allegation is unsubstantiated. It was alleged that staff did not update resident’s care plan. LPA conducted interviews with the Administrator and Resident Service Director, both of whom stated that residents’ care plans are updated as needed when there are any changes in condition. Care plans are discussed with residents and/or residents’ responsible persons and usually stay the same unless any changes are requested. LPA conducted interviews with nine (9) residents. Three (3) residents interviewed have resided less than one (1) year and stated that they have discussed their care plans during the admission process. Five (5) residents interviewed confirmed that their care plans stayed the same after annual meeting. One (1) resident interviewed did not remember if there was any care plan. Based on interviews conducted, the Department’s investigation did not provide enough information to corroborate the allegation that staff did not update resident’s care plan. This allegation is unsubstantiated. It was alleged that staff did not provide timely assistance to resident in care. Information received indicated that there were three (3) instances where only one (1) caregiver on shift at night in the past two weeks. LPA conducted interviews with nine (9) residents, all of whom stated that they have received good services from the caregivers from both day and night shifts. LPA conducted interviews with two (2) staff members, both of whom stated that staff coverage is generally adequate, though shortages occur when a scheduled employee does not show up for work. In those instances, the staff member on duty is required to cover the vacancy. Based on interviews conducted, the Department’s investigation did not provide enough information to corroborate the allegation that staff did not provide timely assistance to resident in care. This allegation is unsubstantiated. Continued on LIC9099-C.... A finding that the complaint is UNSUBSTANTIATED means the allegation may have happened or is valid, but there is not a preponderance of the evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 29, 2026 · control 18-AS-20250204093310

Allegation investigated: Questionable Death

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegation. LPA met with Michael Maeda, Resident Service Director and informed them of the purpose of the visit. The Department’s investigation included interviews with staff and records review. On March 6, 2026, The Department received a complaint report alleging a questionable death. According to the information received, Resident #1 (R1) passed away on March 3, 2026. A Relevant Party (RP) visited R1 on the same day without knowing that R1 had passed away. Staff did not provide any information regarding R1 when RP learned of the passing. During an interview, RP stated they were unaware that R1 had been receiving hospice services. RP also stated that no staff members provided any information about R1’s passing when RP inquired. Continued on LIC9099-C.... Unfounded LPA’s records review revealed that R1 had been under hospice care since February 2026. LPA obtained and reviewed R1’s death certificate, which did not indicate any findings consistent with a questionable or suspicious death. Based on the interviews conducted and records review, the Department did not find evidence to support the allegation of a questionable death. Therefore, the allegation is Unfounded. A finding of “Unfounded” means the allegation could not have happened, is false, and/or lacks a reasonable basis. An exit interview was conducted where a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 29, 2026 · control 18-AS-20260306144310

Allegation investigated: Staff are not meeting resident's hygiene needs Staff allowed resident to be outside without supervision, resulting in a fall Resident was left on the ground outside for an extended period of time

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced visit to the facility to deliver findings of the above allegations. LPA met with Jimmy Stewart, Executive Director and informed them of the purpose of the visit. The Department's investigation involved interviews with staff and residents and review of records. On 10-09-2025, Community Care Licensing (The Department) received a complaint report with the following allegation. It was alleged that staff are not meeting resident’s hygiene needs. According to the information received, Resident #1 (R1) was found to be dirty, unkempt with bruising and ants crawling all over when emergency personnels arrived for R1’s fall incident. LPA reviewed R1’s resident file which revealed R1’s cognitive condition. Continued on LIC9099-C.... Unsubstantiated LPA conducted interviews with three (3) staff members who were present at the time of R1’s fall incident. All three (3) staff members stated that R1 was found in the courtyard between a gazebo and plants on dirt. Two (2) of the three (3) staff members helped R1 up from the ground and put R1 on a wheelchair. R1 was covered in debris, dirt and ants. The staff members dusted off R1, but R1 still had some dirt on their clothes. The staff members brought R1 inside and called 911. Assessing R1 and calling 911 were the priority at the time for the staff members, not dusting off R1 for appearance. LPA attempted to interview R1, but R1 could not answer any questions due to their cognitive condition. LPA conducted interviews with five (5) other staff members, all of whom stated R1 liked being out in the courtyard playing with plants or pebbles while sitting on dirt. R1 always needed to be dusted off by staff whenever coming back inside from the courtyard. Based on file review and interviews conducted, the Department's investigation did not provide enough information to corroborate the allegation that staff are not meeting resident's hygiene needs. This allegation is unsubstantiated. It was alleged that staff allowed resident to be outside without supervision, resulting in a fall. According to the information received, R1 was allowed to be outside alone and fell at some point while unsupervised. LPA conducted R1’s file review, which revealed that R1 was ambulatory without having to use a walker or a wheelchair. R1 was not assessed as fall risk. R1 did not require one-on-one care or frequent check. LPA’s review of facility file revealed all residents were free to go outside in the courtyard for any outdoor activities. LPA observed two (2) doors leading to the courtyard. LPA also observed the courtyard to be surrounded by brick walls protected from traffic. LPA conducted interviews with eight (8) staff members, all of whom stated that all residents are free to go out in the courtyard by themselves, and no resident is under one-on-one care plan. The staff members stated residents were re-directed to come inside anytime after 20 to 30 minutes being outside. Based on file review and interviews conducted, the Department's investigation did not provide enough information to corroborate the allegation that staff allowed resident to be outside without supervision. This allegation is unsubstantiated. It was alleged that resident was left on the ground for an extended period of time. According to the information received, R1 was covered in ants, branches and dirt when emergency personnel arrived. LPA conducted interviews with three (3) staff members who were present during the time of R1’s fall incident. Staff #1 (S1) stated they assisted R1 to bed for a nap shortly after snack time at around 3:30 PM. Later, at approximately 4:40 PM, S1, along with Staff #2 and #3 (S2 and S3), began gathering residents for dinner. Continued on LIC9099-C..... S1 went out to the courtyard to see if any residents were there and found R1 lying on the ground. After briefly speaking to R1 about what happened, S1 returned inside to get help. S1 and S2 then went back outside and assisted R1 into a wheelchair. R1 was brought inside, and S2 called 911. S2 stayed on the phone until emergency personnel arrived. Both S1 and S2 stated it took about 10 minutes until the emergency personnel arrived. LPA’s interview with S3 corroborated the statements made by S1 and S2. LPA attempted to interview R1, but R1 could not answer any questions due to their cognitive condition. None of the staff members could confirm exactly how long R1 had been outside or on the ground. S1 and S2 stated that R1 was already inside the building when the emergency personnel arrived. Based on the time R1 was put to bed and the time they were found, S1 and S2 estimated that R1 could not have been outside for more than 30 to 40 minutes. Based on interviews conducted and information available, the Department's investigation did not provide enough information to corroborate the allegation that resident was left on the ground outside for an extended period of time. This allegation is unsubstantiated. A finding of Unsubstantiated means that the allegation may have occurred or is valid, but there is not a preponderance of evidence to prove that the alleged violation occurred. An exit interview was conducted where a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 2, 2026 · control 18-AS-20251009094043

Allegation investigated: Staff left resident unattended at an off-site location

Licensing Program Analysts (LPAs), Armando Perez and Ivashia Wright, conducted an unannounced visit to deliver findings for a complaint investigation regarding the above allegation. LPA Perez met with Executive Director Jimmy Stewart, and explained both the purpose of the visit and the details of the allegation. On March 11, 2026, the Community Care Licensing Division (CCLD) received a complaint alleging that facility staff left a resident unattended at an off-site location. It was reported that on March 11, Resident 1 (R1) arrived at what they believed was a scheduled medical appointment and was left without confirmation or supervision by facility staff. An interview with the Additional Witness could not be conducted, as the report was submitted anonymously and no contact information was provided to obtain further information. Continued on LIC 9099-C. Unfounded Interview with Executive Director (ED) revealed the facility operates a transportation service daily on weekdays from 8:00 A.M. to 4:00 P.M. The ED explained that residents submit transportation requests through the concierge, and staff verify the address provided; however, staff do not question the purpose of the trip. ED confirmed they were informed of the incident with R1 and noted R1 independently scheduled the appointment which was not directed by staff. Interview with R1 corroborated the ED’s statements. R1 reported that they independently searched for a dentist online and misunderstood the services being provided at the destination they requested. R1 also stated that the driver was contacted immediately after the error was realized and returned within approximately two to three minutes of drop-off. Interview with Staff 2 (S2) indicated that they dropped off R1 and waited until they visually confirmed R1 entered the building. S2 reported they had only just begun to drive away and were still in the parking lot when they received the call to return. S2 stated they acknowledged the request and returned R1 safely back to the facility. A review of the transportation log confirmed that R1 independently requested off-site transport on March 11, including the date, time, and address. A review of medical documents, including the needs and services plan, noted that R1 is able to transfer safely with or without assistance. Additionally, the medical assessment indicates that R1 is permitted to leave the facility unsupervised. A review of the Admissions Record, R1 lists self as responsible party and is able to make their own decisions independently. Based on interviews, research, and record review, the allegations staff left resident unattended at an off-site location is unfounded. A finding that the allegation is unfounded meaning that the allegation was false, could not have happened, and/or is without a reasonable basis. Therefore, this complaint is dismissed. An exit interview was conducted. A copy of this report was provided to Executive Director Jimmy Stewart.the state’s words, verbatim · CDSS document, Mar 18, 2026 · control 18-AS-20260311114143

Allegation investigated: Lack of supervision resulted in resident eloping from the facility.

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 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.the state’s words, verbatim · CDSS document, Oct 18, 2025 · control 18-AS-20221228121355

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Oct 19, 2025

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: 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.the state’s words, verbatim · CDSS document, Oct 18, 2025

Plan of correction: 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.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Seo Jeon conducted an unannounced annual required visit. Upon entry, LPA was greeted by Jimmy Stewart, Executive Director, and informed them of the purpose of the visit. Facility Overview: The facility is a two-story home with (84) bedrooms and (90) bathrooms. There are no known firearms on the premises. Infection Control: LPA observed that hygiene 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: 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. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked and inaccessible to residents. LPA reviewed fire marshal inspection dated 4-8-2025 with no deficiencies. The hot water temperature was 117°F. Fire extinguishers located at hallways have 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. Six (6) resident files were reviewed and contained all required documentation. Health-Related Services/Incidental Medical Services: All resident medications were securely locked in facility medication room. LPA reviewed medications for four (4) 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 4-17-2025, 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.the state’s words, verbatim · CDSS document, Jun 27, 2025

Allegation investigated: Staff failed to meet resident's medical needs Staff neglected resident while in care Staff failed to respond to residents' call assistance buttons in a timely manner Staff failed to meet resident's needs

Licensing Program Analyst (LPA) Sara Martinez arrived unannounced to the facility to conclude the investigation into the allegation listed above. LPA met with Executive Director Jimmy Stewart and explained the purpose of the visit. LPA’s complaint investigation consisted of a tour of the interior/exterior areas of the facility, observations, interviews with staff and residents, and records review of requested pertinent documents. Regarding the allegation “Staff failed to meet resident's medical needs”, Record review of R1’s “Resident Assessment” dated 06/10/2021 reveals R1 was scored on a Level 1 care and was independent, ambulatory, required no assistance with activities of daily living (ADL), and had the capabilities to administer their own medication. Interview with eight (8) residents reported staff would contact emergency services to send to the hospital when needed based on previous experiences or speculation. Interview with six (6) staff members deny ignoring residents’ medical needs and would contact primary physician or emergency services if there was a change in condition. Interview with R1 could not be conducted due to resident’s passing in March 2022. Unsubstantiated Regarding the allegation “Staff neglected resident while in care”, it was reported staff was neglecting R1 and did not meet R1’s needs. Record review of R1’s “Resident Assessment” dated 06/10/2021 reveals R1 was scored on a Level 1 care and was independent, ambulatory, required no assistance with activities of daily living (ADL), and had the capabilities to administer their own medication. Interview with eight (8) out of nine (9) residents deny staff neglecting residents in care and would assist residents when necessary. Interview with six (6) out of (six) staff reported they would assist residents when requested and never witnessed staff neglecting residents in care. Regarding the allegation “Staff failed to respond to residents' call assistance buttons in a timely manner” it was reported staff do not respond to residents’ call button request. Interview with nine (9) out of (9) residents revealed staff respond to residents’ call button request in an adequate amount of time. Interview with five (5) out of six (6) staff revealed staff respond to residents’ call button request as soon as they can and staff response time varies but staff will respond to call button request and assist residents. Investigation did not reveal documents to corroborate nor refute call time responses due to call logs not being available for review. Regarding the allegation “Staff failed to meet resident's needs”, it was reported when R1 returned from the hospital staff were not able to R1’s needs. R1 returned to the facility on 02/21/2022 and had Resident Assessment set at Level 4 care. Level 4 care for R1 reflected direct supervision of R1 and one to two person total assistance with bathing, dressing , grooming, toileting, and ambulation. R1’s Physician’s Report dated 02/22/2022 revealed R1 needed assistance with ADLs, was non-ambulatory, and was not able to administer own medication. Interview with three (3) staff who worked at the facility in 2022 denied not being able to meet the residents needs and corroborated that Level 4 care included direct supervision of the resident and two hour safety checks. Interview with eight (8) residents deny staff failing to meet their needs. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to Executive Director Stewart.the state’s words, verbatim · CDSS document, Aug 19, 2024 · control 18-AS-20220315104748

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Sara Martinez conducted an unannounced annual required visit . LPA was granted entry and met with Jimmy Stewart who was informed of the purpose of the visit. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted interviews. LPA observed the following: Physical plant, floors, windows, and doors were observed to be clean. Fixtures and furniture were in good repair were present. The outdoor area was observed to be free of hazards. LPA observed a courtyard with outdoor furniture and shaded area for residents. Facility contained PPE equipment and cleaning supplies to do regular cleaning of the facility. Cleaning supplies, detergents, and the sharp and dangerous objects were locked and inaccessible to the residents in the facility's janitorial and maintenance supply rooms. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The smoke detector, carbon monoxide, and facility sprinkler system was operational and is maintained annually. LPA tested the hot water temperature in multiple resident bathrooms which met department requirements. 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. LPA was informed the facility receives multiple food deliveries a week. LPA reviewed five (5) staff files and training. All staff have the required personnel records on file and criminal record clearance and updated training along with CPR/First Aid Certification. Five (5) resident files were reviewed, and possessed all required paperwork which included Admissions Agreement, Needs and Service Plan, and Physician's Report. The listed administrator possesses a current administrator's certificate. LPA observed medications are kept locked and inaccessible to residents in the medication room. Medications are labeled. LPA observed a MedTech walking with a medication cart supplying the resident's with their afternoon medication. MedTech documented intake on the facility's electronic Medication Administration Record (eMAR). LPA reviewed client medications for (5) resident and found all medication listed on MARS and all required labeling was found to be in place. Facility has an updated emergency and disaster plan and Infection Control plan. LPA observed all facility exits were clear from obstructions. Facility has a working delayed egress system on the exit doors in the Memory Care Unit. LPA observed emergency supplies and first aid kit with all required items. Facility contained multiple charged fire extinguishers located throughout the facility. Facility had performed a fire drill during the first week of June 2024 which met department requirements. No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to Executive Director Jimmy Stewart.the state’s words, verbatim · CDSS document, Jun 10, 2024

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Yolanda Delgado made an unannounced visit to the facility to conduct a Case Management visit pertaining to a self-report made to RO on 04/25/2024 for verbal abuse to a resident by care staff. LPA Delgado met with Administrator Jimmy Steward to explain the reason for the visit, Administrator stated that Law enforcement was called out and was told that Facility will take care of the matter. Administrator stated that an internal investigation was completed and care staff was disciplined. During the visit, LPA toured the Memory Care unit at the facility and observed residents in an activity with staff present. LPA found no immediate health and safety concern. There is one (1) deficiency will be cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted and a copy of this report, 809-D and Appeal Rights was reviewed with and provided to Facility representative.the state’s words, verbatim · CDSS document, May 3, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: May 8, 2024

Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse...This requirement is not being met as evidenced by: S1 and S1 verbally abused R1 and was witnessed by W1 and W2. This poses a potential health and safety risk to the clients in care.the state’s words, verbatim · CDSS document, May 3, 2024

Plan of correction: Licensee has reprimanded S1 and S2 and will conduct in-service training with all staff that have direct-care with residents and submit copy to LPA by POC due date.

Allegation investigated: Facility staff do not assist resident with transfers. Facility staff are not meeting resident's care needs.

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. Unfoundedthe state’s words, verbatim · CDSS document, Apr 5, 2024 · control 18-AS-20240403150931