336410691-8-30-2024-18-AS-YDEO-D8MSNQ-20240830140156

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 336410691
Report Date: 08/30/2024
Date Signed: 08/30/2024 02:02:04 PM

Document Has Been Signed on 08/30/2024 02:02 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	BROOKDALE MIRAGE INN		FACILITY NUMBER:	336410691
ADMINISTRATOR:	SPAUN, JOHN		FACILITY TYPE:	740
ADDRESS:	72750 COUNTRY CLUB DR		TELEPHONE:	(760) 346-7772
CITY:	RANCHO MIRAGE	STATE: CA	ZIP CODE:	92270
CAPACITY:	145	CENSUS: 111	DATE:	08/30/2024
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Rene Montesinos, Health &Wellness Director		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Yolanda Delgado arrived unannounced to complete the Annual inspection that was started on 8/23/2024. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction, visit purpose and provided the facility with LPA identification. Physical Plant and Safety of Environment/Operational Requirements- LPA toured the facility inside and outside. The facility is maintained at a comfortable temperature for the clients. Lighting is sufficient for safety and comfort. Water temperature measured 111.0 degrees F. Laundry facilities and a locked cabinet is present for storing laundry soap and other chemicals. All outdoor and indoor passageways are free of obstruction. A locked area is provided for medications and sharp objects. LPA verified there is a telephone working at this location. LPA observed a pool with perimeter gate that is secured, alarmed and locked. Food Service- Food supply meets the requirement of one week supply of nonperishable and 2 day supply of perishables food on hand. A menu is posted, foods are dated to assure safety. Food prep areas are clean and organized. LPA began review of employee records- Nine (9) records were reviewed. LPA reviewed employee record for first aid certification, fingerprint clearance, personnel/job application, health screening and TB test results, criminal record statement, employee rights, training verification, and current administrator certification. CPR and requirements have been met. The facility employs enough staff to maintain cleanliness and meet the needs of the clients in care. Administrator certification is present and current. (Continued on Page 2)

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: BROOKDALE MIRAGE INN	FACILITY NUMBER: 336410691
	VISIT DATE: 08/30/2024

NARRATIVE

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(Continued from Page 1)

LPA made observation throughout the inspection process to assess if the facility remains in conformity with the State Fire Marshall regulations. The facility has not exceeded its capacity limitation and the structure remains unchanged according to the approved floor plan. Smoke detectors and carbon monoxide detectors were tested and found to be operational. Fire extinguishers are tested or replaced annually and were last done so on 11/09/2023. The facility is conducting emergency disaster drills. The last disaster drill was conducted on 7/2/2024.

LPA allocated time to prepare this report for delivery.

Based on the information received during this visit today, there are no deficiency that is being cited per Title 22, Division 6 of The California Code of Regulations.

This report was reviewed with and a copy provided to the facility representative at the time of the exit interview.

SUPERVISOR'S NAME: Jazmond D Harris	TELEPHONE: (951) 248-0318
LICENSING EVALUATOR NAME: Yolanda Delgado	TELEPHONE: (951) 203-2990
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2024

LIC809 (FAS) - (06/04)

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