331880702-7-19-2022-18-AS-DMUN-CJRU8G-20220930152131

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880702
Report Date: 07/19/2022
Date Signed: 07/19/2022 10:51:06 AM

Substantiated

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 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/12/2022 and conducted by Evaluator Stephanie Torres

PUBLIC

COMPLAINT CONTROL NUMBER: 18-AS-20220712091125

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: 3	DATE:	07/19/2022
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Victoria Theobald, Administrator		TIME COMPLETED:	10:55 AM

ALLEGATION(S):

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Facility did not obtain liability insurance

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Stephanie Torres, conducted an unannounced visit to the facility to initiate the investigation into the above allegation. The LPA met with Administrator, Victoria Theobald, and informed her of the purpose of her visit.

Pertaining to the allegation, "Facility did not obtain liability insurance," it was alleged Administrator Theobald did not carry proper state mandated insurance for the facility during the time period of May 2020 through September 2020. Theobald was interview and reported the allegation was true. She stated she has not obtained liability insurance since the facility was licensed in 2019. Therefore, based on interview, this allegation is deemed SUBSTANTIATED. A finding that the complaint is substantiated means the allegation is valid because the preponderance of the evidence standard has been met. A citation will be issued in accordance with the California Code of Regulations (Title 22, Division 6, Chapter 8). An exit interview was conducted; this report was reviewed with Theobald and a copy was provided, along with the Appeal Rights.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 18-AS-20220712091125

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 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MIRAGE ELDERLY CARE	FACILITY NUMBER: 331880702
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/19/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/19/2022 Section Cited CCR 1569.605	1 2 3 4 5 6 7	LIABILITY INSURANCE; COVERAGE REQUIREMENTS: On and after 07/01/15, all RCFEs...shall maintain liability insurance covering injury to residents & guests in the amount of at least $1,000,000 per occurrence & $3,000,000 in the total annual aggregate...This requirement was not met,	1 2 3 4 5 6 7	The Administrator stated she would provide proof of liability insurance by POC due date.
	8 9 10 11 12 13 14	as evidenced by: Based on interview the Licensee did not ensure liability insurance was maintained for the facility. The Administrator stated she has not obtained liability insurance since the facility was licensed in 2019. This poses a potential threat to the health & safety of the residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Deborah Mullen	TELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Stephanie Torres	TELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

LIC9099 (FAS) - (06/04)

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