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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880702
Report Date: 12/03/2021
Date Signed: 12/03/2021 04:50:06 PM

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 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:MIRAGE ELDERLY CAREFACILITY NUMBER:
331880702
ADMINISTRATOR:THEOBALD, VICTORIAFACILITY TYPE:
740
ADDRESS:1 CALAIS CIRTELEPHONE:
(760) 328-6400
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY:6CENSUS: 3DATE:
12/03/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:20 PM
MET WITH:Victoria TheobaldTIME COMPLETED:
12:25 PM
NARRATIVE
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On 12/3/21 Licensing Program Analyst (LPA) Shaunte Henry conducted an unannounced case management visit for the purpose of addressing a deficiency for the facility. The LPA met with Victoria Theobald, explained the nature of the visit and was granted entry.

During an audit investigation by the Department for complaint # 18-AS-20200707112241, licensee, Victoria Theobald failed to provide an admission agreement for Resident 1 (R1).

R1’s admission agreement dated 4/2/20 for a private room and a monthly rate of $5,500 was reviewed. This was an acceptable rate to charge. The licensee was unable to provide an admission agreement for R1’s initial placement on 3/28/20 for a shared room for the amount of $3,500. This a Title 22 Regulation violation, therefore this allegation is SUBSTANTIATED.

Based on THE LPAs observations and interviews, which were conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6) is being cited on the attached LIC 809D.

An exit interview was conducted where this report, 809D, 811 and appeal rights were provided to Victoria Theobald.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MIRAGE ELDERLY CARE
FACILITY NUMBER: 331880702
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/03/2021
Section Cited

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Admission Agreement: The licensee shall retain the original signed and dated admission agreement and all modifications. This requirement was not met as evidence by:
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Based on obseravations, the licensee was unable to produc a copy of Resident 1 (R1)’s original admission agreement dated 3/8/20.
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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: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:
DATE: 12/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/03/2021
LIC809 (FAS) - (06/04)
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