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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005718
Report Date: 01/07/2025
Date Signed: 01/07/2025 06:29:39 PM

Document Has Been Signed on 01/07/2025 06:29 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
ORANGE COUNTY RO, 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: 5DATE:
01/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Maria Garcia TIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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On 01/07/2025 Licensing Program Analyst (LPA) William Vanegas made an unannounced visit for the purposes of annual visit. Upon arrival LPA Vanegas was greeted and granted entry to the facility by administrator (AD) Maria Garcia. LPA Vanegas explained the purpose of the visit and set up equipment once granted entry into the facility. LPA Vanegas conducted a tour of the facility and observed the following.

This is a two storied home with seven bedrooms four of which are resident rooms, one of which is a staff room, and two of which are personal living quarters for licensee. This facility has four bathrooms two are resident bathrooms and two are for staff and visitors. The facility also has an attached two car garage. LPA Vanegas observed the kitchen to be clean and free of debris. LPA Vanegas observed a two day supply of perishable food and a seven day supply of non-perishable food with a sufficient amount of emergency water.

LPA Vanegas observed a gas stove, microwave, dish washer, washer, and a dryer that were all tested and tested operational. Medications were observed to be centrally stored, locked, and inaccessible to residents in care. LPA Vanegas observed that there was no documentation that indicates the time and days that medications were being taken. Bubble packs were popped on different days making it unclear as to when the medications were taken or not. A deficiency was cited on today's date.

LPA Vanegas observed smoke and carbon monoxide detectors to be operational, fire extinguisher was observed to be fully charged and up to date. LPA Vanegas observed resident bathrooms to be clean and free of debris and contained all required furnishings such as grab bars, slip resistant matts, and functional faucets and toilets. Water tested between 112.4- 114.8 degrees.

CONTINUED ON LIC809C
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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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Document Has Been Signed on 01/07/2025 06:29 PM - It Cannot Be Edited


Created By: William Vanegas On 01/07/2025 at 04:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MIRAGE MANOR HOME CARE
FACILITY NUMBER: 306005718

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of three staff files not containing the required training which poses a potential safety risk to persons in care.
POC Due Date: 01/21/2025
Plan of Correction
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Administrator stated she will provide the training that is required and send proof of completion to LPA via email by POC due date.
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as licensee did not have a record available for review at the time of visit which poses potential health risk to persons in care.
POC Due Date: 01/21/2025
Plan of Correction
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Licensee stated she would began documenting the medication administratoin beginng tomorrow and will send proof of correction to LPA via email by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Armando J Lucero
LICENSING EVALUATOR NAME:William Vanegas
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2025


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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: MIRAGE MANOR HOME CARE
FACILITY NUMBER: 306005718
VISIT DATE: 01/07/2025
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LPA Vanegas observed all resident rooms to be clean and sanitary and containing all required furnishings such as chest drawers, reading lamps, windows that are screened, a bed, a chair, storage space for personal belongings, and linens that are in good repair meaning no strains or tears. LPA Vanegas observed all the required postings to be posted however the PUB 475 posting was not the correct size a technical violation was given on today's date.

LPA Vanegas reviewed five resident files and all resident files consisted of the required documents. LPA Vanegas also observed three staff records and one of the three staff records did not contain the required annual training a deficiency was cited on today's date.

LPA Vanegas observed the backyard of the facility to be clean and consist of a seated area available to residents. LPA Vanegas observed the exit routes to be clean and free of debris. There are two exit routes that are not obstructed by any objects and the doors are self latching and unlocked.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: William Vanegas
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC809 (FAS) - (06/04)
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