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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208995
Report Date: 09/21/2022
Date Signed: 09/21/2022 02:14:41 PM


Document Has Been Signed on 09/21/2022 02:14 PM - 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:
09/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:51 AM
MET WITH:Senior Executive Director Linda PopeTIME COMPLETED:
10:52 AM
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On 9/21/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and met with Senior Executive Director Linda Pope. LPA tour facility with Senior Executive Director.

Upon entry facility staff was observed with facial covering. Visitor log-in/temperature check was observed at the front entrance. Hand washing station observed at front entrance. Social distancing is maintained in the common. Covid-19 related signs and posting were observed in the common areas and throughout the halls in the facility. LPA observed all staff with facial covering during tour.

Food supply was checked and appeared to be an adequate supply. LPA observed fire extinguisher served date: 07/29/22. LPA checked residents’ locked medications. LPA observed 30-day PPE supplies.

Facility has multiple designated visitation areas available. Bathrooms are observed with securely fastened grab bars and non-skid mat. Bathrooms observed trash bin with lid. Hand washing posting observed by bathroom sinks. A sample of resident records reviewed to have updated emergency contact information. LPA observed documentation of staff infection control training.

No deficiencies issued during this inspection.

Exit Interview conducted. LPA received copy of Lic 308, Lic 610E, and current liability insurance. A copy of this report was provided to Administrator via email. Signature one file.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022
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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