Inspection Reports for Bayshire Rancho Mirage
72201 Country Club Dr, Rancho Mirage, CA 92270, United States, CA, 92270
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, with the facility generally clean, well-maintained, and compliant with health, safety, and care requirements. Several complaint investigations were unsubstantiated, including allegations of physical abuse, inadequate staffing, and COVID-19 protocol violations. Some deficiencies were cited in 2023 and 2024 related to resident personal rights, including verbal abuse by staff, failure to report suspected abuse, and delayed responses to resident needs, but these issues were isolated and addressed with staff discipline and citations. The most recent report from June 27, 2025, was free of deficiencies, indicating improvement since earlier findings. No fines or license suspensions were listed in the available reports.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
1.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
60% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
82% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 111
Capacity: 135
Deficiencies: 0
Date: Jun 27, 2025
Visit Reason
The inspection was an unannounced annual required visit conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be clean, well-maintained, and in compliance with infection control, physical plant, food service, care and supervision, record keeping, medication management, and disaster preparedness requirements. No deficiencies were cited during the visit.
Report Facts
Bedrooms: 84
Bathrooms: 90
Hot water temperature: 117
Staff files reviewed: 5
Resident files reviewed: 6
Resident medications reviewed: 4
Fire drill date: Apr 17, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jimmy Stewart | Executive Director | Met with Licensing Program Analyst during inspection |
| Seo Jeon | Licensing Program Analyst | Conducted the inspection visit |
| Scott Kirby | Administrator | Facility administrator holding current administrator’s certificate |
Inspection Report
Complaint Investigation
Census: 114
Capacity: 135
Deficiencies: 0
Date: Aug 19, 2024
Visit Reason
The inspection visit was an unannounced complaint investigation conducted in response to allegations received on 2022-03-15 regarding staff failing to meet residents' medical needs, neglect, delayed response to call assistance buttons, and failure to meet resident needs.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff failing to meet resident's medical needs, neglect, failure to respond timely to call buttons, and failure to meet resident needs. Interviews and record reviews did not provide sufficient evidence to prove the allegations.
Findings
The investigation included interviews, observations, and record reviews. Interviews with residents and staff generally denied the allegations. Records showed changes in resident care levels, and no conclusive evidence was found to substantiate the complaints. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 135
Census: 114
Resident Assessment Date: Jun 10, 2021
Resident Return Date: Feb 21, 2022
Physician Report Date: Feb 22, 2022
Number of residents interviewed: 8
Number of staff interviewed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sara Martinez | Licensing Program Analyst | Conducted the complaint investigation |
| Jimmy Stewart | Executive Director | Met with Licensing Program Analyst during investigation |
| Tricia Danielson | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 104
Capacity: 135
Deficiencies: 0
Date: Jun 10, 2024
Visit Reason
An unannounced annual required visit was conducted to evaluate the facility's compliance with licensing regulations.
Findings
The facility was found to be clean, well-maintained, and in compliance with safety and health requirements. Staff files, resident records, medication management, emergency plans, and safety equipment were all in order. No deficiencies were cited during the inspection.
Report Facts
Staff files reviewed: 5
Resident files reviewed: 5
Food supply duration: 2
Food supply duration: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jimmy Stewart | Executive Director | Met during inspection and exit interview |
| Sara Martinez | Licensing Program Analyst | Conducted the inspection |
| Tricia Danielson | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Complaint Investigation
Census: 107
Capacity: 135
Deficiencies: 1
Date: May 3, 2024
Visit Reason
The inspection was an unannounced Case Management visit triggered by a self-report made on 2024-04-25 regarding verbal abuse of a resident by care staff.
Complaint Details
The visit was complaint-related due to a self-report of verbal abuse by care staff. An internal investigation was completed, care staff was disciplined, and law enforcement was involved. The deficiency was substantiated.
Findings
The Licensing Program Analyst found one deficiency related to verbal abuse by a staff member towards a resident, posing a potential health and safety risk. No immediate health and safety concerns were observed during the visit.
Deficiencies (1)
Personal Rights of Residents in All Facilities: Residents shall be free from punishment, humiliation, intimidation, abuse. This requirement was not met as S1 verbally abused R1, witnessed by W1 and W2, posing a potential health and safety risk.
Report Facts
Deficiencies cited: 1
Capacity: 135
Census: 107
Plan of Correction Due Date: May 8, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jimmy Stewart | Administrator | Met with Licensing Program Analyst regarding the verbal abuse incident |
| Yolanda Delgado | Licensing Program Analyst | Conducted the inspection and authored the report |
| Jazmond D Harris | Licensing Program Manager | Supervisor of the inspection |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 135
Deficiencies: 0
Date: Apr 5, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that facility staff do not assist residents with transfers and are not meeting residents' care needs.
Complaint Details
The complaint was investigated and found to be unfounded, meaning the allegations were false, could not have happened, or were without reasonable basis.
Findings
The investigation found that the complaint was unfounded because the resident involved was admitted only to the Skilled Nursing Facility, which is outside the jurisdiction of the Community Care Licensing. Therefore, the allegations were determined to be false or without reasonable basis.
Report Facts
Capacity: 135
Census: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rob McFarlane | Administrator in Training | Met with Licensing Program Analyst during the complaint investigation |
| Kathleen Banrasavong | Licensing Program Analyst | Conducted the complaint investigation |
| Jazmond D Harris | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 135
Deficiencies: 1
Date: Sep 25, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 12/09/2022 regarding staff handling and speaking inappropriately to a resident.
Complaint Details
The complaint investigation involved allegations that Staff One (S1) handled Resident One (R1) roughly and spoke inappropriately to R1. The rough handling allegation was unsubstantiated due to insufficient evidence, while the inappropriate speech allegation was substantiated based on staff interviews and evidence, leading to a citation.
Findings
Two allegations were investigated: one regarding rough handling of a resident, which was deemed unsubstantiated due to lack of sufficient evidence; and another regarding inappropriate speech by staff to a resident, which was substantiated and resulted in a citation for violation of resident personal rights.
Deficiencies (1)
Failure to ensure resident was accorded dignity in personal relationships with staff, evidenced by staff making inappropriate statements and arguing with the resident without attempts to de-escalate.
Report Facts
Capacity: 135
Census: 101
Plan of Correction Due Date: Oct 25, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Martinez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Michael Maeda | Resident Services Director | Met with the Licensing Program Analyst during the investigation and was involved in exit interviews |
| Scott Kirby | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 101
Capacity: 135
Deficiencies: 1
Date: Sep 25, 2023
Visit Reason
The inspection was an unannounced visit conducted to address a violation observed during the investigation of complaint #18-AS-20221209144911 involving alleged physical and verbal assault.
Complaint Details
The visit was complaint-related, investigating complaint #18-AS-20221209144911. The complaint involved an alleged physical and verbal assault on Resident One by Staff One. The incident was not reported to appropriate agencies as mandated, despite initial suspicion of abuse.
Findings
The investigation revealed that a suspected abuse incident involving a resident and staff was not reported to the appropriate agencies as required, due to an internal investigation that could not corroborate the incident. A citation will be issued for failure to report.
Deficiencies (1)
Failure to report suspected physical abuse of a resident to the local ombudsman, licensing agency, and law enforcement within 24 hours as required.
Report Facts
Capacity: 135
Census: 101
Deficiency count: 1
Plan of Correction Due Date: Oct 25, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Maeda | Resident Services Director | Met with Licensing Program Analyst during the inspection and was informed of the purpose of the visit |
| Stephanie Martinez | Licensing Program Analyst | Conducted the unannounced visit and authored the report |
| Rikesha Stamps | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Annual Inspection
Census: 102
Capacity: 135
Deficiencies: 2
Date: Jun 19, 2023
Visit Reason
An unannounced annual required visit was conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility generally met infection control, physical plant, food service, medication management, and disaster preparedness requirements. However, deficiencies were found related to inadequate care and supervision of a resident and an unassociated staff member working at the facility.
Deficiencies (2)
Based on observation and interview, the licensee did not comply with care and supervision requirements during the visit; resident #1 was outside in the sun for an unknown amount of time without staff assistance, posing an immediate health, safety, or personal rights risk.
Staff member #1 was not associated with the facility, posing an immediate health, safety, or personal rights risk to persons in care.
Report Facts
Staff present: 10
Resident files reviewed: 5
Staff files reviewed: 5
Bedrooms: 121
Bathrooms: 128
Food deliveries per week: 4
Hot water temperature (F): 119
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Holm | Administrator | Met with Licensing Program Analyst during inspection and named in findings |
| Sara Martinez | Licensing Program Analyst | Conducted the inspection |
| Joel Esquivel | Licensing Program Manager | Supervisor of the Licensing Program Analyst |
Inspection Report
Census: 102
Capacity: 135
Deficiencies: 0
Date: Jun 12, 2023
Visit Reason
The visit was an unannounced follow-up to an incident report regarding a resident having suicidal ideation.
Complaint Details
The visit was triggered by a complaint related to a resident's suicidal ideation. No deficiencies or substantiated issues were found.
Findings
No immediate health and safety concerns were found. The resident's care plan was updated and the facility has oversight of the incident. No deficiencies were noted at the time of the visit.
Report Facts
Capacity: 135
Census: 102
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Holm | Executive Director | Met with Licensing Program Analyst during the visit |
| Chinwe Nwogene | Licensing Program Analyst | Conducted the unannounced visit and follow-up |
| Joel Esquivel | Licensing Program Manager | Named in the report header |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 135
Deficiencies: 2
Date: May 9, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-08-31 regarding multiple allegations about resident care and facility operations at Bayshire Rancho Mirage.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not respond timely to Resident 1's requests for assistance and failed to develop a care plan for Resident 1's oxygen needs. Other allegations were unsubstantiated.
Findings
The investigation substantiated allegations that staff did not respond timely to a resident's requests for assistance and failed to develop a care plan for the resident's oxygen needs. Other allegations including unclean rooms, mail delivery issues, inadequate staff training, medication mismanagement, overcharging, and safeguarding personal items were found to be unsubstantiated.
Deficiencies (2)
Failure to provide care plans and ensure oxygen needs were met for Resident 1, posing immediate health and safety risk.
Delayed staff response to resident call button pushes, posing potential personal rights risk.
Report Facts
Resident button pushes: 16
Average staff response time (minutes): 9.15
Facility capacity: 135
Resident census: 104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Gardner | Licensing Program Analyst | Conducted the complaint investigation and delivered findings. |
| Janette Romero | Licensing Program Analyst | Assisted in conducting the complaint investigation and delivering findings. |
| Brittany Holm | Administrator | Met with LPAs during the investigation and exit interview. |
| Michael Maeda | Resident Services Director | Met with LPAs during the investigation and exit interview. |
Inspection Report
Complaint Investigation
Census: 105
Capacity: 135
Deficiencies: 0
Date: Apr 27, 2023
Visit Reason
An unannounced visit was made to collect documentation and interview residents in relation to complaint number 18-AS-20210831170004.
Complaint Details
Visit was related to complaint number 18-AS-20210831170004; no substantiation status stated.
Findings
The Licensing Program Analyst met with the Executive Director, toured the facility, and interviewed three residents. An exit interview was conducted and a copy of the report was provided.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brittany Holm | Executive Director | Met with Licensing Program Analyst during the visit. |
| Jesse Gardner | Licensing Program Analyst | Conducted the unannounced visit, collected documentation, interviewed residents. |
| Deborah Mullen | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 103
Capacity: 135
Deficiencies: 0
Date: Dec 30, 2022
Visit Reason
The visit was an unannounced complaint investigation initiated due to a complaint received on 2022-12-29 alleging that staff do not assist a resident with getting out of bed.
Complaint Details
The complaint alleged that staff do not assist Resident One with getting out of bed. The allegation was investigated and deemed unfounded based on interviews and evidence.
Findings
The investigation found the allegation to be unfounded after interviews with staff, the resident, and the Executive Director. The resident denied the allegation and staff reported the resident has remained in bed due to directions from family and specialized care providers, with the resident coming out for meals.
Report Facts
Capacity: 135
Census: 103
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Torres | Licensing Program Analyst | Conducted the complaint investigation |
| Brittany Holm | Executive Director | Met with Licensing Program Analyst during investigation and provided information |
Inspection Report
Complaint Investigation
Census: 104
Capacity: 135
Deficiencies: 1
Date: Dec 12, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 09/09/2021 alleging that staff did not inform a resident's authorized representative of issues concerning the resident.
Complaint Details
The complaint was substantiated. It was found that the facility notified only one of the two Powers of Attorney listed for resident R1 about the falls, failing to notify both as required.
Findings
The complaint was substantiated as the facility failed to notify both of the resident's Powers of Attorney about the resident's falls, which is a violation of Title 22. The facility was cited for not meeting reporting requirements.
Deficiencies (1)
Failure to notify both Powers of Attorney of resident R1's falls as required by Title 22 reporting requirements.
Report Facts
Capacity: 135
Census: 104
Deficiencies cited: 1
Plan of Correction Due Date: Jan 11, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Gardner | Licensing Program Analyst | Conducted the complaint investigation and cited the deficiency |
| Michael Maeda | Resident Services Director | Met with Licensing Program Analyst during the investigation |
| Deborah Mullen | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 100
Capacity: 135
Deficiencies: 0
Date: Nov 9, 2022
Visit Reason
An unannounced complaint investigation visit was conducted following allegations that staff did not safeguard a resident's personal belongings and that the facility did not have adequate staff to meet residents' needs.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included missing personal belongings (a wedding ring) and inadequate staffing. Interviews, record reviews, and resident statements did not support the allegations.
Findings
The investigation found that the facility provided necessary tools to safeguard the resident's belongings and that staffing levels were adequate to meet residents' needs. Both allegations were found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Residents present: 100
Licensed capacity: 135
Assisted living census: 76
Average care staff: 15.8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Gardner | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Deborah Mullen | Licensing Program Manager | Named in report as Licensing Program Manager |
| Brittany Holm | Administrator | Facility administrator met during the investigation and exit interview |
Inspection Report
Annual Inspection
Census: 93
Capacity: 135
Deficiencies: 0
Date: Jun 22, 2022
Visit Reason
An unannounced annual inspection was conducted with an emphasis on infection control.
Findings
The inspection found sufficient hand hygiene supplies, cleaning and disinfecting provisions, proper use of face coverings, sufficient PPE supplies, and staff training on COVID-19. No deficiencies were cited during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maria Juarez | Nursing Director | Met with Licensing Program Analyst during the inspection. |
| Stephanie Torres | Licensing Program Analyst | Conducted the unannounced annual inspection. |
| Deborah Mullen | Licensing Program Manager | Named in the report header. |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 135
Deficiencies: 0
Date: Jan 25, 2022
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that residents were being physically abused by staff.
Complaint Details
The allegation was that residents, including Resident One (R1), were being physically abused by staff. The complaint was investigated and found to be unfounded based on interviews and record review.
Findings
The investigation found no evidence to support the allegation. Interviews and resident roster review indicated the named resident was not at the facility, and the complaint was deemed unfounded.
Report Facts
Capacity: 135
Census: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Torres | Licensing Program Analyst | Conducted the complaint investigation |
| Brittany Holm | Executive Director | Met with the Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 77
Capacity: 135
Deficiencies: 0
Date: Oct 19, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2021-08-31 regarding staff not following CDC guidelines for COVID-19 prevention and administering COVID vaccine without resident's authorized representative consent.
Complaint Details
The complaint included two allegations: 1) Staff did not follow CDC guidelines for preventing the spread of COVID-19, specifically not wearing masks when entering a resident's room; 2) Staff administered COVID vaccine without resident's authorized representative consent. Both allegations were determined to be unsubstantiated.
Findings
The investigation found both allegations to be unsubstantiated after interviews and observations. Staff were observed following COVID-19 protocols including mask wearing and visitor screening, and consent for vaccination was confirmed.
Report Facts
Capacity: 135
Census: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jesse Gardner | Licensing Program Analyst | Conducted the complaint investigation and made findings |
| Roland Gandy | Director | Met with Licensing Program Analyst during investigation |
Inspection Report
Original Licensing
Census: 76
Capacity: 135
Deficiencies: 0
Date: Aug 27, 2021
Visit Reason
The inspection was a post licensing visit to confirm the facility name and address, and to verify compliance following the initial licensing of the facility on 06/01/2021.
Findings
The facility was found to be licensed for 135 non-ambulatory residents with a hospice waiver for 20. There was a confirmed COVID-19 positive resident, but the facility completed a second round of COVID testing on 08/26/2021 and is following approved COVID-19 mitigation procedures. Communal activities are temporarily suspended pending negative test results.
Report Facts
Residents in assisted living: 52
Residents in memory care: 24
Hospice waiver capacity: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Roland Gandy | Director of Assisted Living | Spoke with Licensing Program Analyst and participated in facility tour |
| Chardonnay Blue | Lead Nurse | Participated in facility tour with Licensing Program Analyst |
Inspection Report
Original Licensing
Census: 70
Capacity: 135
Deficiencies: 0
Date: Jun 1, 2021
Visit Reason
The visit was conducted as an announced pre-licensing inspection for a Residential Care Facility for the Elderly (RCFE) to evaluate readiness for licensure.
Findings
The facility was found to be in good condition with no obstructions, operable safety detectors, sufficient and secure storage, adequate food service equipment, and proper posting of required signs. The fire clearance was granted for 135 non-ambulatory residents, including 15 bedridden.
Report Facts
Fire clearance capacity: 135
Hot water temperature: 108.3
Hot water temperature: 108.5
Hot water temperature: 108.9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Roland Gandy | Administrator | Met during inspection and discussed report findings |
| Stephanie Torres | Licensing Program Analyst | Conducted the pre-licensing inspection |
| Scott Kirby | Licensee | Met during inspection |
Inspection Report
Original Licensing
Census: 69
Capacity: 135
Deficiencies: 0
Date: May 18, 2021
Visit Reason
The visit was conducted as a change of ownership application evaluation for the facility, including verification of the applicant/administrator's identity and understanding of California Code Title 22 regulations.
Findings
The applicant/administrator demonstrated understanding of facility operation, admission policies, staffing requirements, restricted health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness during a telephone interview.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Roland Gandy | Executive Director | Applicant/administrator participating in COMP II interview and confirmed understanding of regulations. |
| Jude De La Concepcion | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Bethany Hunter | Licensing Program Analyst | Named as Licensing Program Analyst on the report. |
Inspection Report
Original Licensing
Capacity: 135
Deficiencies: 0
Date: May 10, 2021
Visit Reason
The visit was conducted as part of a Change of Ownership application process for the facility, including verification of applicant and administrator identification and confirmation of understanding of California Code Title 22 regulations.
Findings
The applicant and administrator participated in a telephone interview confirming understanding of facility operation, admission policies, staffing requirements, restrictive health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness. Signed documentation and photo ID were obtained.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dwayne Davis | Administrator | Facility administrator named in the report. |
| Scott Kirby | President | Participant in COMP II telephone interview. |
| Jude De La Concepcion | Licensing Program Manager | Named as Licensing Program Manager. |
| Bethany Hunter | Licensing Program Analyst | Named as Licensing Program Analyst. |
Report
March 18, 2026
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Nov 25, 2025
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October 18, 2025
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Apr 24, 2025
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May 3, 2024
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Apr 17, 2024
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Jan 11, 2024
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Nov 8, 2023
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Aug 9, 2023
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Aug 3, 2023
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Jul 20, 2023
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Jul 17, 2023
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Jun 8, 2023
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May 15, 2023
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Dec 9, 2022
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