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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880574
Report Date: 03/18/2022
Date Signed: 03/18/2022 01:04:57 PM

Document Has Been Signed on 03/18/2022 01:04 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:MIRA VISTA MANORFACILITY NUMBER:
331880574
ADMINISTRATOR:ZAECH, CYNDYFACILITY TYPE:
740
ADDRESS:8 VIA SOLANATELEPHONE:
(760) 250-8990
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY: 6CENSUS: 6DATE:
03/18/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:07 PM
MET WITH:Elizabeth Franco, CaretakerTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Jesse Gardner arrived unannounced to conduct a health and safety check of the facility. LPA was met with Caretaker Elizabeth Franco, and they accompanied LPA on a tour of the facility.

The health and safety check included an overall tour of the facility including all resident rooms, bathrooms, confirmed the required 7-day non-perishable, 3-day perishable food supply, outside area, and inside the facility.

LPA observed sufficient staffing while at the facility. There were no health and safety concerns noted during the visit.

At the conclusion of the visit, LPA observed no deficiencies during today's inspection.

LPA noted that the Licensee needs to provide an updated LIC200, LIC309, and LIC500 and submit to LPA by 03/25/2022.

An exit interview was conducted and a copy of this report was discussed with and provided to Ms. Franco.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2022
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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