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Facility Number: 330910677
Effective Date: 08/20/91 Total Capacity: 4
Expiration Date: 08/19/92
In accordance with applicable provisions of the Health and Safety Code of
California, and its rules and regulations, the Department. of Social Services, hereby issues
Ir `
RAMIREZ• FANNY
to operate and maintain a RESIDENTIAL-6ELDERLY
NttmP of Attriti#y
LA OUINTA RESIDENCE
53-800 OBREGON
LA OUINTA CA 92253
This License is not transferable and is granted solely upon the following:
4 AMBULATORY CLIENTS AGE 60t.
Client Groups Served: ELDERLY
Complaints regarding services provided in this facility should be directed to:
RIVERSIDE DISTRICT OFFICE •(714111:782-1t200 1-800-4—CCLii-NOM
^ w
IFRED Y. MILLER 101
Deputy Director, Autho'riied Representative Issue Date
Community Care Licensing Division of Licensing Agency
UC 203A 0 /87) PUB UC
POST IN A PROMINENT PLACE
mm
11111111�ffl
•
PLEASE PAINT OR TYPE
�f�pac�a st rM
�MWEIMIN
WILLIAM E. CONERLY
COUNTY
. ,,",°S Submit original end 2 copies.
- COUNTY CLERK 2. Filing Fee: Statement Including one registrant, $17.00; each additional
name at same location, add $5.00; each additional registrant, add 55.00..
P.O. BOX 751
OCT 16 1001
a Provide self-addressed stamped envelope, if mailed.
-RIVERSIDE, CA 92502-0751 4. Must be, legible - make no erasures, whiteouts or other alterations.
SEEREVERSE SIDE FOR INSTRUCTIONS
"U" 'E.'00NERLY, ,,Q "
FICTITIOUS =,BUSINESS NAME ,STA'.I r-11VIMW V
THE FOLLOWING PERSONS IS ARE DOING BUSINESS AS:
Fictitious Business Name(s)
LA QUINTA RESIDENCyf ELDERi� CARE
Street Address, City & State of'Principal Place of Business in California Zip Code
53-800 AVE. OBREGON LA QUINTA,CA 92253-3545' �£
Full Name of Registrant (one),
Full Name of Registrant (two)
FANNY RAMIREZ
Residence Address
Residence Address
53-800 Ave.Obregon_La Quinta,CA
City State Zip
City State Zip
La Quinta CA 92253-3545
(If corporation, show state of incorporation)
(If corporation, show state of incorporation)
Full Name of Registrant. (three)
Full Name of Registrant (four)
Residence Address _
Residence Address
City State Zipr
City State, ,. „ < < Zip
(If corporation, show state of incorporation) -
(If corporation, show'state of incorporation)
(It More Than 4 Registrants — Attach Additional Sheet Showing Owner Information)
`..This business is conducted by: an -individual •.'O :Individuals=Husband Band Wife' ' ::O -66 -General Partnership
❑ a Limited Partnership ❑ a Corporation ; ❑ a Business Trust^ ❑ Co?Partners , O'a Joint Venture.,
{
O anUnincorporated Association"*ther than a Partnership - `' `❑ 'Other (Specify)
This registrant commenced to transact business the ficthious'business or listed 40/14[91 '
under name names above on a
w If Registrant a corporation sign below.
Sign — Corporation Name
Typed or Printed \ 7: ''' j.� �'I''.' !•' ...r .:-'L' Signature & Title
Type or Print
Officer's Name & Title
THE FILING OF THIS STATEMENT DOES NOT OF ITSELF AUTHORIZE THE USE IN THIS STATE OF A FICTITIOUS BUSINESS NAME
IN VIOLATION OF THE RIGHTS OF ANOTHER UNDER FEDERAL, STATE, OR COMMON LAW (SEC. 14400 ET. SEQ. B & P CODE)
STATEMENT FILED WITH THE COUNTY CLERK OF RIVERSIDE COUNTY ON DATE INDICATED BY FILE STAMP ABOVE
NOTICE - THIS FICTITIOUS BUSINESS NAME STATEMENT
I HEREBY CERTIFY THAT THIS COPY IS A CORRECT COPY
EXPIRES 5 YEARS FROM THE DATE THIS STATEMENT IS
OF THE ORIGINAL STATEMENT ON FILE IN MY OFFICE.
FILED WITH THE COUNTY CLERK'S OFFICE. RENEWAL OF THIS
STATEMENT MUST BE FILED PRIOR TO THE DATE OF
WILLIAM E. CONERLY, County Clerk
EXPIRATION.
BY DEPUTY
- 912283
FILE NO.
FORM 500 (Rev 7/90)
Pay to the C j
order o
WESTERN BANK M
A Feft 39*4p Bw* 40
46.2M TOWNE AVE.
6410, CA MMI
For C's -VOL) Atl eL--iA-, (T-fti Weng N
1: 3 2 2 2 ? 00 3 9 1:
59
No. (()
.. 199, 7003/3222
$ 3 -z-