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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005718
Report Date: 05/16/2024
Date Signed: 05/16/2024 01:38:43 PM

Document Has Been Signed on 05/16/2024 01:38 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MIRAGE MANOR HOME CAREFACILITY NUMBER:
306005718
ADMINISTRATOR/
DIRECTOR:
GARCIA,MARIAFACILITY TYPE:
740
ADDRESS:1630 W CRIS AVETELEPHONE:
(714) 956-1005
CITY:ANAHEIMSTATE: CAZIP CODE:
92802
CAPACITY: 6CENSUS: 6DATE:
05/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Maria Garcia TIME VISIT/
INSPECTION COMPLETED:
01:50 PM
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Licensing Program Analysts (LPAs) Jerome Haley and conducted an unannounced visit for the purpose of conducting a required one-year annual inspection. LPA Haley was greeted and granted entry by staff and explained the reason for the visit.

During the inspection, LPA Haley observed all resident bedrooms and bathrooms. All resident bedrooms had the necessary elements and were in compliance with regulation guidelines. Hot water temperatures were measured in the range of 110 degrees Fahrenheit and 119 degrees Fahrenheit.

In the kitchen, knives and sharp objects are kept locked at the bottom of the medication cabinet. At the top of the medication cabinet, there were two first aid kits with all the required elements. A perishable food supply that meets regulation requirements was observed in the refrigerator. A non-perishable food supply that meets regulation requirements was observed in the cabinets.

The garage is used to store miscellaneous items. Walkways were free of obstruction. There was an addition refrigerator with an additional food supply. In the center of the garage there’s several facility items that are no longer being used. There was an emergency supply of water and an additional perishable food supply. A washer and dryer was observed and above the washer and dryer is a locked cabinet with soaps, detergents, and other cleaning items.

On the way to the backyard there's a large room used as a facility office and used to store boxes of diapers, paperwork, and old files. The backyard was organized, and free of clutter. A table and chairs was observed. A locked shed used to store additional items was observed.

A fully charged fire extinguisher was observed mounted on the wall near the dining room. Administrator Garcia will have the extinguisher serviced or replaced. Photos will be sent to LPA Haley. There are locked cabinet in the dining room area used to store staff, and resident files.

Continued on LIC809C

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2024
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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: MIRAGE MANOR HOME CARE
FACILITY NUMBER: 306005718
VISIT DATE: 05/16/2024
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Smoke carbon monoxide detectors tested operational.

During the inspection, LPA Haley reviewed, resident medication, and conducted interviews with residents and staff.

An exit interview was conducted, and a copy of this report was provided.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC809 (FAS) - (06/04)
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