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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881086
Report Date: 04/27/2023
Date Signed: 04/27/2023 03:02:00 PM


Document Has Been Signed on 04/27/2023 03:02 PM - It Cannot Be Edited

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:BAYSHIRE RANCHO MIRAGEFACILITY NUMBER:
331881086
ADMINISTRATOR:KIRBY, SCOTTFACILITY TYPE:
741
ADDRESS:72201 COUNTRY CLUB DRIVETELEPHONE:
(760) 340-5999
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY:135CENSUS: 105DATE:
04/27/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Executive Director Brittany HolmTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Jesse Gardner made an unannounced visit to collect documentation, and interview residents in relation to complaint number 18-AS-20210831170004.

LPA met with Executive Director Brittany Holm and received documentation. LPA then toured the facility and interviewed Resident 1 (R1), Resident 2 (R2), and Resident 3 (R3).

An exit interview was conducted and a copy of this report was discussed with and provided.
SUPERVISOR'S NAME: Deborah MullenTELEPHONE: (951) 248-0313
LICENSING EVALUATOR NAME: Jesse GardnerTELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2023
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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