Bayshire Rancho Mirage.

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.

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..... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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.

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.

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...... 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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.

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.

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. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 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.