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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880702
Report Date: 01/28/2021
Date Signed: 01/29/2021 07:56:38 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-26
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/09/2020 and conducted by Evaluator Shaunte Henry
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200909132052
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: 6DATE:
01/28/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Victoria Theobald, licensee/administratorTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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Licensee married a current resident at her facility
INVESTIGATION FINDINGS:
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On 1/28/2021 Licensing Program Analyst (LPA) Shaunte Henry conducted a tele-inspection due to COVID-19 in order to deliver the finding to the above allegation. LPA Henry spoke with Licensee Victoria Theobald and explained the purpose of the tele-inspection.

The investigation consisted of file review and interviews. An interview with the licensee revealed that the licensee married Resident 1 (R1). LPAs observation confirmed that a state of Nevada marriage certificate was filed at the Clark County Recorder's office on 7/4/2020.

Based on LPA's observations and interviews, which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Health and Safety Code 1550(c) is being cited on the attached LIC9099D.

An exit interview was conducted where this report was discussed with and provided to the licensee via email.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Edna MusokeTELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 18-AS-20200909132052
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/29/2021
Section Cited
HSC
1550(c)
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Licenses or administrator Certificates; suspension, revocation or denial of application; grounds: The department may...revoke, any license, or any special permit, certificate of approval, or administrator certificate, issued under this chapter upon any of the following : (2) Conduct which is inimical to the health, morals, welfare or safety
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Licensee shall ensure that all staff is conducting themselves in a professional manner and shall not take advantage of residents vulnerability. Licensee will read the health and safety code and submit a statement of understanding regarding inimical conduct.
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of either the people of this state or an individual in, or receiving services from the faciltiy or certified family home. This
requirement is not met as evidenced by: Interviews and record reviews revealed Victoria Theobald married R1 on 7/4/2020. This poses an immediate health and safety risk to R1.
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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: Edna MusokeTELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2