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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881366
Report Date: 02/07/2023
Date Signed: 02/07/2023 10:57:13 AM


Document Has Been Signed on 02/07/2023 10:57 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:
02/07/2023
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Staff, Gabriela AlvarezTIME COMPLETED:
11:15 AM
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Licensing Program Analysts (LPA) Janira Arreola and Jacqueline Shaw Ross conducted an announced visits in order to verify completion of items identified during the pre licensing visit on 1/31/2023. LPA met with Staff, Gabriela Alvarez who was informed of the purpose of the visit.


The applicant for the license was not present during the time of the Visit. Therefore, the visit will need to be rescheduled for another day.

An exit interview was conducted where this report was reviewed and provided to Staff, Gabriela Alvarez
SUPERVISOR'S NAME: Joel EsquivelTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023
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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