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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005718
Report Date: 02/05/2025
Date Signed: 02/05/2025 11:39:11 AM

Document Has Been Signed on 02/05/2025 11:39 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MIRAGE MANOR HOME CAREFACILITY NUMBER:
306005718
ADMINISTRATOR/
DIRECTOR:
GARCIA,MARIAFACILITY TYPE:
740
ADDRESS:1630 W CRIS AVETELEPHONE:
(714) 956-1005
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
02/05/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Maria Garcia TIME VISIT/
INSPECTION COMPLETED:
11:40 AM
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On February 5th, 2025 Licensing Program Analyst (LPA) William Vanegas made an unannounced visit for the purposes of a case management visit due to a Special Incident Report (SIR) received by the Orange Regional Office. SIR stated that resident sustained a small spinal fracture due to a fall that occurred at the facility. Upon arrival LPA Vanegas was greeted and granted entry to the facility by Care Giver (CG) Maria Garcia and LPA Vanegas explained the purpose of the visit.

LPA Vanegas reviewed resident's file, resident's discharge paperwork, and two staff files that were present at the time of the incident and reviewed the following. Per resident discharge paper work resident was diagnosed with a Lumbar Vertebral Fracture. Per residents physician report resident is non-ambulatory and requires assistance with activities of daily living (ADL). Resident is also diagnosed with dementia.


Per LPA Vanegas review of staff files, both staff members that were present are trained on care for individuals diagnosed with dementia, and postural supports. LPA Vanegas interviewed staff member that was present and a staff member that was not present and obtained the following information. Resident had just eaten dinner right before the fall, he was transferred from the dinning table to the living room couch. He was sitting close to the edge of the sofa and staff members were in the kitchen where they still had visual of the resident however they noted him scooting closer to the edge of the couch and observed him sliding down the couch where he subsequently fell and sustained his injury.

LPA Vanegas attempted to interview resident however he could not recall the incident. Resident stated that he feels safe here, and that the staff treat him with respect, and he enjoys living here. Based on today's observations and interviews there is no risk to the resident's health or safety. No deficiencies will be cited based on title 22 regulations. An exit interview was conducted and a copy of this report was left at the facility
Armando J LuceroTELEPHONE: (714) 703-2866
William VanegasTELEPHONE: (714) 497-7621
DATE: 02/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2025
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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