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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880574
Report Date: 08/09/2022
Date Signed: 08/09/2022 11:25:49 AM

Document Has Been Signed on 08/09/2022 11:25 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:
08/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:06 AM
MET WITH:Elizabeth Franco, StaffTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA), Stephanie Torres, made an unannounced visit to the facility to conduct an annual inspection, with an emphasis on infection control. The LPA met with Staff, Elizabeth Franco, and informed her of the purpose of her visit. There are currently no cases of COVID-19 within the facility.

During today's visit, the LPA toured the facility and made observations pertaining to the facility's infection control measures. The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, and that staff are trained in the proper use and disposal of PPE and overall infection control. The facility has an Infection Control Plan in place. The facility also has a plan in place to monitor residents regularly for any changes in condition and to subsequently notify the resident's physician and to notify all emergency agencies in the event of any COVID-19 related and/or suspected illnesses.

No proof of Administrator Certification was observed on file. A citation will be issued.

An exit interview to review this report was conducted with Franco and a copy of this report was provided, along with Appeal Rights.
SUPERVISORS NAME: Deborah Mullen
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2022
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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Document Has Been Signed on 08/09/2022 11:25 AM - It Cannot Be Edited


Created By: Stephanie Torres On 08/09/2022 at 11:12 AM
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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: MIRA VISTA MANOR
FACILITY NUMBER: 331880574

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87406(a)
Administrator Certification Requirements: All individuals shall be residential care facility for the elderly certificate holders prior to being employed as an administrator. 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. No Administrator certificate was observed on file for Cyndy Zaech, the Licensee and Administrator. This poses a potential health, safety and/or personal rights risk to persons in care.
POC Due Date: 08/16/2022
Plan of Correction
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Proof of Administrator certification will be submitted to the Department
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Deborah Mullen
LICENSING EVALUATOR NAME:Stephanie Torres
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022


LIC809 (FAS) - (06/04)
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