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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881366
Report Date: 01/31/2023
Date Signed: 01/31/2023 11:18:51 AM


Document Has Been Signed on 01/31/2023 11:18 AM - 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: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: 6DATE:
01/31/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Applicant Chet KhayTIME COMPLETED:
11:40 AM
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Licensing Program Analyst s(LPA) Janira Arreola and Jacqueline Shaw Ross, conducted an announced visit for the purpose of conducting the prelicensing inspection on 01/31/2023 at 9:50 a.m. LPA met with Applicant Chet Khay and Ruth Kay for the visit. The applicant is seeking a change of ownership for an residential care facility for the elderly with a capacity for (6) residents, ages 60 and up.

LPA conducted a walk through of the interior and exterior of the facility. The home is a (5) bedroom and (4) bathroom, one story home with attached garage. The fire clearance conducted on 11/10/2022 by Rancho Mirage Fire Department was approved the home for (1) ambulatory resident in bedroom #1. LPA observed the room and located the exit that is required. The other resident bedrooms were observed to have the appropriate linens, furniture such as bed, dresser, closet space, light, night stand and chair. The home has extra linens and bath towel in the garage which was locked. First aid kit was observed to have all required supplies in medication closet. LPA observed the emergency flash lights in the facility garage. The facility kitchen has enough pots and pans, cooking utensils, plates and cups for (6) Residents. The kitchen had the appropriate perishable and non-perishable food items. LPA observed the bathrooms in the facility to have hand hygiene supplies, and personal care items for residents. The facility possesses cleaning supplies to conduct regular cleaning of the facility. These items are kept located in hallway pantry. The smoke alarms and carbon monoxide detectors were found in working condition. The dining room has enough seating for (6) residents, and the outdoor space has enough seating for (6) residents LPA observed the home has activities for clients to engage in. The hot water temperature was recorded in the kitchen sink at 110F, and the land line was observed to be operational (760-464-0882). Facility pool has a locked gate surrounding it. NO firearms are being kept in the facility. Kitchen knifes will be kept locked in hallway pantry.

LPA was informed by staff that the facility laundry equipment is not currently functioning. The facility has a plan to do resident laundry. The administrator stated that this should be fixed within a week. A follow up visit will be required before the applicant proceeds in the pre-licensing process.

An exit interview was conducted were this report was reviewed and provided to the Applicant Chet Khay.
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
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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