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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336408433
Report Date: 08/02/2023
Date Signed: 08/02/2023 04:13:04 PM


Document Has Been Signed on 08/02/2023 04:13 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:VISTA COVE AT RANCHO MIRAGEFACILITY NUMBER:
336408433
ADMINISTRATOR:JACK POYFAIRFACILITY TYPE:
740
ADDRESS:70201 MIRAGE COVE DRIVETELEPHONE:
(760) 324-4604
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY:68CENSUS: 51DATE:
08/02/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:36 PM
MET WITH:Jack Poyfair, AdministratorTIME COMPLETED:
04:15 PM
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On July 27, 2023 LPA, Stephanie Martinez, removed facility records from the facility. The LPA returned all records to the facility on this date. The records were removed to assist in the investigation of complaint #18-AS-20230724152734.

This report was reviewed with Administrator, Jack Poyfair, and a copy was provided
SUPERVISOR'S NAME: Jazmond D HarrisTELEPHONE: (951) 782-4807
LICENSING EVALUATOR NAME: Stephanie MartinezTELEPHONE: (951) 204-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 08/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/02/2023
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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