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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880574
Report Date: 04/06/2022
Date Signed: 04/06/2022 10:04:25 AM

Document Has Been Signed on 04/06/2022 10:04 AM - 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) 656-4037
CITY:RANCHO MIRAGESTATE: CAZIP CODE:
92270
CAPACITY: 6CENSUS: 6DATE:
04/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Elizabeth Franco, CaretakerTIME COMPLETED:
10:10 AM
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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 (S1), 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, and a tour of the kitchen and food supply. The required food supply per Title 22 Division 6 Article 10 87555(b)(26) was not adequate; thus, a Technical Violation was issued. Licensee to provide proof of food delivery via email by today's date. Also, upon review of the LIC500, LPA found a caretaker (S2) not to be associated with the facility. S2 has a fingerprint clearance, but is not associated to the facility. LPA observed a completed transfer request form; however the information was not placed into Guardian. Licensee to complete the association through Guardian. LPA observed sufficient staffing while at the facility. There were no further 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 remaining items to be obtained are as follows:
  1. Lease Agreement
  2. Articles of Incorporation
  3. Death Certificate
  4. Documents from Secretary of State

Licensee to deliver these items to the Department no later than 4/20/2022. 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: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2022
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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