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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336410691
Report Date: 08/24/2021
Date Signed: 08/24/2021 11:18:18 AM

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 INNFACILITY NUMBER:
336410691
ADMINISTRATOR:SPAUN, JOHNFACILITY TYPE:
740
ADDRESS:72750 COUNTRY CLUB DRTELEPHONE:
(760) 346-7772
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY:145CENSUS: 105DATE:
08/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:56 AM
MET WITH: Jessalette CastroTIME COMPLETED:
11:25 AM
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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility for a required annual inspection, with an emphasis on the infection control domain. LPA met with Jessalette Castro, Business Office Manager, who confirmed there are no active Covid-19 cases in the community. LPA toured the facility with Castro and Marcus Buckles, Maintenance Director.

The facility submitted a mitigation plan to Community Care Licensing (CCL) to mitigate the spread of COVID-19 in the facility. Entry points open to the main lobby and a sign-in policy has been designated for universal entry screening. The facility also documents daily temperature and COVID-19 symptom checks for all visitors while residents are subject to routine symptom screening and regular observation for any change in condition. Continued weekly routine testing for staff is still observed. LPA observed all staff are properly fitted with face coverings.

LPA Bueno toured the facility’s common rooms and an empty private apartment. Buckles verified that the smoke detectors and fire alarms are maintained on a call system and monitored by an outside vendor. Buckles stated the systems were checked about 2-3 months ago and the carpets are cleaned at least once a month. Charged fire extinguishers are checked monthly, the most recent inspection was on 7/29/21. LPA observed hand sanitizer throughout the facility, mostly situated next to common bathrooms. Castro also confirmed the facility has an adequate supply of Personal Protective Equipment (PPE) and cleaning and disinfectant provisions.

LPA Bueno observed no health and safety concerns at the time of visit. Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. An exit interview was conducted where this report was discussed, and a copy of this report was also provided to Castro at the conclusion of the inspection.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 248-0339
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
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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