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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208996
Report Date: 09/13/2021
Date Signed: 09/13/2021 03:47:49 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 MEMORY CAREFACILITY NUMBER:
107208996
ADMINISTRATOR:POPE, LINDAFACILITY TYPE:
740
ADDRESS:2145 STANFORD AVETELEPHONE:
(559) 322-8500
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:48CENSUS: 24DATE:
09/13/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:13 PM
MET WITH:Linda PopeTIME COMPLETED:
03:44 PM
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LPA was met by Linda Pope, Senior Executive Director and stated the purpose of the visit. A tour of the facility was conducted, COVID-19 guidelines are in place. Visitor log-in/temperature check was observed upon entry at facility entrance/exit point, all staff and visitors enter through facility main entrance. Hand sanitizer was readily available to residents and visitors, as well as hand washing station. COVID-19 related signs were observed in the common area and through out the halls in facility. LPA Medina observed all facility staff wearing masks.

LPA checked residents’ medications and observed a 30-day supply. LPA observed a 2-day of perishable and a 7-day of non-perishable food available. Cleaning and PPE supplies were checked, 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. Administrator was informed that as a COVID-19 precautionary measure, this report will be emailed.
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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