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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208995
Report Date: 09/13/2021
Date Signed: 09/13/2021 01:13:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:CARMEL VILLAGE AT CLOVISFACILITY NUMBER:
107208995
ADMINISTRATOR:POPE, LINDAFACILITY TYPE:
740
ADDRESS:1650 SHAW AVENUETELEPHONE:
(559) 297-4900
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:127CENSUS: 69DATE:
09/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Linda Pope TIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Melinda Medina conducted an unannounced Annual Required Infection Control Inspection. LPA Medina met with Senior Executive Director, Linda Pope and discussed the purpose of the visit. LPA Medina toured entire facility and grounds with Senior Executive Director.

Upon entrance, LPA Medina observed a visitor log/temperature check and disinfection station at the front entrance. Facility has one entry and exit point. Hand sanitizer was readily available to residents and visitors, as well as hand washing station. Hand washing and other various Covid-19 related signs were observed in the common area and through out the halls in facility. LPA Medina observed residents in various areas of the facility and physically distanced 6 feet apart. LPA Medina observed all facility staff wearing masks.

LPA Medina observed a two day supply of perishable food and seven day supply of non-perishable food. LPA Medina observed the following personal protective equipment in a storage room; gowns, goggles, gloves, and masks. Fire extinguisher has a service date of 6/24/2021. Water temperature measured at 120 degrees F. LPA Medina observed designated area for staff training records regarding Covid-19 mitigation and infection control. Resident’s files have updated emergency contact information.

The following documents requested by LPA Medina to be updated and submitted to Fresno CCL by 9/20/21: LIC 500, LIC 610, LIC 9020. LPA received copy of Administrator Certificate and First Aid card during facility inspection.

No deficiencies were observed. Exit interview was conducted with Executive Director and a copy of this report will be provided by e-mail..
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021
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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