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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208995
Report Date: 10/02/2023
Date Signed: 10/02/2023 06:02:26 PM


Document Has Been Signed on 10/02/2023 06:02 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
SIERRA CASCADE AC/SC, 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: 82DATE:
10/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator Linda Pope and Health Service Coordinator Stacie PantojaTIME COMPLETED:
04:07 PM
NARRATIVE
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On 10/02/23, Licensing Program Analyst (LPA) M. Yang arrived at the facility unannounced to conduct the Required Annual Inspection. LPA were greeted by receptionist, stated the purpose of the visit and met with Administrator (A1) Linda Pope. LPA conducted tour of facility with A1 and Health Service Coordinator Stacie Pantoja. Residents were observed seating in dining area and activity room.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards. Fire extinguisher was observed with a service date of: 06/27/23.

Kitchen was toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in walk-in freezer and walk-in refrigerator. Refrigerator temperature was observed checked at 06:00AM maintained at 34 degree F. and freezer was observed maintained at -10 degree F.

Medications were stored in a locked medication room in a medication cart. MARs and medications were reviewed.Residents' rooms were toured and observed with adequately furnished with bed, dresser, and adequate lighting. LPA observed securely fastened grab bars and non-skid mat in all tub/shower areas.

LPA toured in 1st floor: a sample of resident bedrooms, activity room, club room, dining room and fitness center.

2nd floor toured: a sample of resident bedrooms, library, and den.

3rd floor toured: a sample of resident bedrooms, den, lounge.

SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: CARMEL VILLAGE AT CLOVIS
FACILITY NUMBER: 107208995
VISIT DATE: 10/02/2023
NARRATIVE
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A sample of staff files were reviewed to have the required documents. A sample of resident’s files were reviewed to have all the required documents.

A deficiency is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6.



An exit interview was conducted. LPA received copy of Lic 308, Lic 500, Lic 610E, Administrator certificate, current liability insurance. A copy of this report and appeal rights was provided to the Administrator, whose signature on this form confirm receipt of these reports.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 10/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/02/2023 06:02 PM - 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: CARMEL VILLAGE AT CLOVIS
FACILITY NUMBER: 107208995

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87465(c)
Medications must be given per the physician’s direction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when LPA, Administrator and Health Service Coordinator reviewed residents’ MARS and medications. LPA and Health Services Coordinator observed R1 medication was not given as directed which poses an immediate health, safety or personal rights risk to person in care.
POC Due Date: 10/03/2023
Plan of Correction
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POC of documentation of how the facility shall ensure medications are administered as directed by resident’s physicians due by 10/03/23. In-service training on administering medication will submit with documentation of training topics and staff attendance roster to the Fresno CCL office by 10/13/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2023
LIC809 (FAS) - (06/04)
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