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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412451
Report Date: 03/29/2024
Date Signed: 03/29/2024 02:13:09 PM


Document Has Been Signed on 03/29/2024 02:13 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:BRENTWOOD OF RANCHO MIRAGE IIFACILITY NUMBER:
336412451
ADMINISTRATOR:DVILLAR/RVILLAR CO-ADMINFACILITY TYPE:
740
ADDRESS:26 BUCKINGHAM WAYTELEPHONE:
(760) 321-2239
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY:6CENSUS: 4DATE:
03/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:House Manager, Imelda Villar TIME COMPLETED:
02:30 PM
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On 3/29/2024, Licensing Program Analyst (LPA) Janette Romero conducted an unannounced visit to the facility for a required annual inspection. LPA met with House Manager (HM), Imelda Villar who was informed of the purpose of the visit. LPA toured the facility’s interior and exterior with HM Villar. The facility has a fire clearance for six (6) non-ambulatory elderly residents and an approved hospice waiver for two (2). During today’s visit, there was four (4) residents and two (2) staff present.

The facility is made up of three (3) resident bedrooms and two (2) full bathrooms along with a kitchen, living room, dining room and attached garage. During the tour, LPA observed the facility has more than a 2-day supply of perishable food and 7-day supply of nonperishable foods that are stored in a safe and healthful manner. Medications are secured in a kitchen cabinet. Disinfectants and cleaning solutions are secured in a locked cabinet in the laundry room. The outside area provides shaded seating available for resident use. Indoor and outdoor passageways are free of obstruction. The facility has an in-ground pool, which is appropriately gated and secured with a master lock, making it inaccessible for the residents in care. HM Villar tested the smoke alarm/carbon monoxide detectors, and LPA found them to be operational. LPA observed charged fire extinguishers mounted throughout the facility. LPA reviewed random resident files. Files reviewed had signed admission agreements and updated physician’s reports. The facility does not safeguard residents' cash resources. LPA reviewed random staff files. Files reviewed had the Department’s required training records and a valid first aid certification. During today’s visit, LPA did not observe any issues or concerns. An exit interview was conducted, and a copy of this report was reviewed and provided to HM Villar via email due to LPA experiencing technical difficulties. LPA waited to ensure that HM Villar accessed and printed the report.
SUPERVISOR'S NAME: Tricia DanielsonTELEPHONE: (951) 202-5067
LICENSING EVALUATOR NAME: Janette RomeroTELEPHONE: (951) 529-2930
LICENSING EVALUATOR SIGNATURE:
DATE: 03/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/29/2024
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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