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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336410691
Report Date: 05/04/2021
Date Signed: 05/04/2021 05:02:55 PM

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 MS29-26
RIVERSIDE, CA 92507
FACILITY NAME:BROOKDALE MIRAGE INNFACILITY NUMBER:
336410691
ADMINISTRATOR:SPAUN, JOHNFACILITY TYPE:
740
ADDRESS:72750 COUNTRY CLUB DRTELEPHONE:
(760) 346-7772
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY:145CENSUS: DATE:
05/04/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Usbaldo Martinez, Executive DirectorTIME COMPLETED:
05:00 PM
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On 5/3/21 Licensing Program Analyst (LPA) Shaunte Henry conducted a health and safety check in conjunction with complaint # 18-AS-20210503144834. There were no health and safety concerns noted.

A copy of this report was discussed with and provided to the Executive Director Usbaldo Martinez.
SUPERVISOR'S NAME: Edna MusokeTELEPHONE: (951) 248-0336
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2021
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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