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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881366
Report Date: 01/06/2023
Date Signed: 01/06/2023 02:49:53 PM


Document Has Been Signed on 01/06/2023 02:49 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:RANCHO MIRAGE SENIOR LIVINGFACILITY NUMBER:
331881366
ADMINISTRATOR:KHAY, CHETFACILITY TYPE:
740
ADDRESS:5 SHASTA LAKE DRIVETELEPHONE:
(760) 464-0882
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY:6CENSUS: DATE:
01/06/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Chet & Ruth KhayTIME COMPLETED:
02:35 PM
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COMP II by CAB successfully completed

Facility Type: RCFE
Application Type: Change of Ownership
Capacity: 6
Census (if any clients in care): 5
Method: Telephone call - CAB with applicants
COMP II Participants: Chet Khay & Ruth Khay

Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant and administrator was verified by photo ID. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant has been advised to transmit signed LIC 809 to CAB.
SUPERVISOR'S NAME: Julia KimTELEPHONE: (916) 651-7848
LICENSING EVALUATOR NAME: Dianne RamosTELEPHONE: (916) 653-5973
LICENSING EVALUATOR SIGNATURE:
DATE: 01/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2023
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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