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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881366
Report Date: 03/14/2024
Date Signed: 03/14/2024 10:51:23 AM


Document Has Been Signed on 03/14/2024 10:51 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: 4DATE:
03/14/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Chet Khay, Garrett Peterson, Terrye PetersonTIME COMPLETED:
10:50 AM
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On March 14, 2024, an office meeting was conducted regarding information obtained pertaining to the property being sold and deficiencies cited during the Annual inspection on February 28, 2024. In attendance for the meeting was Licensing Program Manager (LPM), Jazmond Harris, Licensing Program Analyst (LPA), Yolanda Delgado, Licensee Chet Khay and Applicants, Garrett Peterson and Terrye Peterson.

The Department provided and reviewed Health and Safety Code section 87109 for guidance on transferability of License. Licensee advised that he sold the property to Terrye Peterson and Garret Peterson on February 19, 2024. Licensee stated he will provide the written notification to licensing. Garrett Peterson submitted the application (LIC200) March, 2024.

Licensee stated he informed the residents and/or responsible parties within the required 60 Days.

Licensee acknowledged and understood that he is responsible for the facility and operations, care and supervision of clients under his license until the new owners obtain a license.

An exit interview was conducted, where this report was reviewed and provided to Licensee.

SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda DelgadoTELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2024
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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