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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107208995
Report Date: 08/23/2022
Date Signed: 08/23/2022 02:00:56 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/16/2022 and conducted by Evaluator Mai Yang
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20220816153825
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: 79DATE:
08/23/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Linda Pope, Administrator TIME COMPLETED:
01:33 PM
ALLEGATION(S):
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Facility not following admission agreement
INVESTIGATION FINDINGS:
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On 08/23/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced and conducted an initial complaint investigation. LPA met with Administrator Linda Pope and explained the purpose of the visit and delivered finding.

During the course of the investigation, the Department conducted interview and records were reviewed. Department investigated the complaint alleging that facility not following admission agreement. Documentation obtained and reviewed, as well as interview conducted show that Licensee applied surcharge fee to resident that was not in the admission agreement.

Based on interview conducted and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Under California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC 9099D. Plan of correction was discussed with the Administrator. An exit interview was conducted, and a copy of this report and appeal rights was provided to Administrator.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 24-AS-20220816153825
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: CARMEL VILLAGE AT CLOVIS
FACILITY NUMBER: 107208995
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2022
Section Cited
CCR
87507(g)(B)
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Admission Agreements (g) Admission agreements shall specify the following:
(B) Rate for additional items and services

This requirement is not met as evidenced by:
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Licensee shall submit a plan of steps that will be taken to ensure the regulation is met by the due date.
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Based on records reviewed and interview conducted, the licensee did not comply with the section cited above. Licensee applied surcharge fee to resident that was not included in the admission agreement, which poses/posed a potential health, safety or personal rights risk to persons in care.
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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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2