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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208995
Report Date: 09/22/2022
Date Signed: 09/22/2022 09:14:26 AM


Document Has Been Signed on 09/22/2022 09:14 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, 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: 79DATE:
09/22/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:19 AM
MET WITH:Senior Executive Director Linda PopeTIME COMPLETED:
09:15 AM
NARRATIVE
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On 9/22/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Case Management-Deficiencies. LPA introduced self, stated the purpose of the visit, and met with Senior Executive Director Linda Pope. LPA tour facility with Senior Executive Director.


The purpose of today's inspection is to address the facility's failure to submit Incident Reports to the Fresno Community Care Licensing (CCL) office on: 09/06/22.

A deficiency is being cited, per California Code of Regulations, Title 22, Division 6, see attached Lic 809D.

An exit interview was conducted. A Plan of Correction was reviewed and developed with Administrator. As COVID-19 precautionary measure, this report and appeal rights was to Senior Executive Director via email.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022
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 09/22/2022 09:14 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2022
Section Cited

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87211(a)(1) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports… (1) A written report shall be submitted to the licensing agency ...within seven days of the occurrence of any of the events…

This requirement is not met as evidenced by:
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Based on record review: Licensee did not ensure a written report was submitted to the Fresno CCL office within 7 days of occurrence on 09/06/22. Licensee submitted written report of incident to CCL on 09/14/22, which this poses a potential health and safety risk to residents 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: 09/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2022
LIC809 (FAS) - (06/04)
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