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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005718
Report Date: 02/23/2022
Date Signed: 02/23/2022 01:30:28 PM


Document Has Been Signed on 02/23/2022 01:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:MIRAGE MANOR HOME CAREFACILITY NUMBER:
306005718
ADMINISTRATOR:GARCIA,MARIAFACILITY TYPE:
740
ADDRESS:1630 W CRIS AVETELEPHONE:
(714) 956-1005
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY:6CENSUS: 5DATE:
02/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Ofelia Santos and Maria Garcia TIME COMPLETED:
01:42 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by Administrator (AD) Maria Garcia and Licensee Ofelia Santos and I explained to her the reason for my visit today. LPA observed all required postings on the wall throughout the facility. AD Garcia has a current administrators certificate that expires on 06/05/2023. LPA observed a screening log book, and temperature thermometer for screening clients and visitors. At 11:05am LPA toured the facility with AD Garcia. There were five residents in care at the facility. All appeared to be happy and well taken care of. Two residents were observed watching TV, while the others were relaxing in their room. LPA began the tour with AD Garcia checking client rooms and bathrooms. Client rooms have the necessary requirements, night stand, chair, lamp and storage space. Bathrooms were clean and operational. LPA measured the water temperature at 109.9 degrees Fahrenheit. The facility has a two day supply of perishable food items and seven days supply of nonperishable food items. There was a first aid kit equipped with all required items in the locked medication cabinet in the kitchen. The knives and sharp objects were also locked in the medication cabinet. The stove was clean and all burners were operational. All hazardous chemical are locked below the sink. The facility has adequate PPE supply of gloves, N95 mask, surgical mask, and hand sanitizers. LPA observed extra linen, emergency food and water supply. LPA toured the backyard and observed both side exit gates of the house were self closing and self latching. LPA observed tables and chairs for the residents in care. At 11:19am while touring the back yard with AD Garcia, LPA observed a pile of brick and dirt debris and a wheel barrel. AD stated that the brick wall was just repaired and the man working on the wall will come and remove all the debris left behind. LPA also observed four old car tires along the brick wall and a separate pile of cement blocks/tiles near by. LPA advised AD Garcia the importance of keeping the backyard free of clutter. AD stated all the debris will be removed from the backyard area, and will send LPA pictures to show the clean up was completed. There were no bodies of water observed. All smoke detectors were tested and are operational. Deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapter 8. A copy of the LIC809d and LIC9102 were explained and provided. An exit interview was conducted and a copy of the report was provided to the Administrator Maria Garcia.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/23/2022 01:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: MIRAGE MANOR HOME CARE
FACILITY NUMBER: 306005718

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/23/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(a)(e)(1)


(a)The department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, residence, or presence in the facility, based upon the results of such review.
(e)All individuals subject to a criminal record review pursuant to Health and SafetyCode Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:
(1) Obtain a California clearance or a criminal record exemption as required by the department or
Deficient Practice Statement
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Based on observation and record review of Mariacrmela working in the facility at time of the annual inspection, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/24/2022
Plan of Correction
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The licensee will make sure all employees have the proper and complete criminal record review before working in the facility.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 02/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/23/2022
LIC809 (FAS) - (06/04)
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