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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881366
Report Date: 10/28/2023
Date Signed: 10/28/2023 11:32:38 AM


Document Has Been Signed on 10/28/2023 11:32 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:
10/28/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Heather Acosta-Support Staff TIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the following complaints control numbers.

CONTROL NUMBER- 18-AS-20210324090309 and CONTROL NUMBER- 18-AS-20210324090309.

LPA Allen met with Janet Munoz who was informed of the purpose of the visit. The administrator granted staff approval for signing report.

An exit interview was conducted where this report was discussed and provided to Heather Acosta at the conclusion of the visit.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Bernadette AllenTELEPHONE: (951) 897-2618
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2023
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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