<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
331880702
Report Date:
04/09/2021
Date Signed:
04/09/2021 11:14:16 AM
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
1650 SPRUCE ST STE 200 MS29-26
RIVERSIDE
,
CA
92507
FACILITY NAME:
MIRAGE ELDERLY CARE
FACILITY NUMBER:
331880702
ADMINISTRATOR:
THEOBALD, VICTORIA
FACILITY TYPE:
740
ADDRESS:
1 CALAIS CIR
TELEPHONE:
(760) 328-6400
CITY:
RANCHO MIRAGE
STATE:
CA
ZIP CODE:
92270
CAPACITY:
6
CENSUS:
4
DATE:
04/09/2021
TYPE OF VISIT:
Case Management - Health Checks
UNANNOUNCED
TIME BEGAN:
11:00 AM
MET WITH:
Victoria Theobald, licensee/administrator
TIME COMPLETED:
11:20 AM
NARRATIVE
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
On 4/9/21 Licensing Program Analyst (LPA) Shaunte Henry conducted a welfare check in conjunction with priority 1 complaint investigation # 18-AS-20210407124520. There were no safety concerns observed.
SUPERVISOR'S NAME:
Edna Musoke
TELEPHONE:
(951) 248-0336
LICENSING EVALUATOR NAME:
Shaunte Henry
TELEPHONE:
(951) 217-0236
LICENSING EVALUATOR SIGNATURE:
DATE:
04/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
04/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
1