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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208996
Report Date: 10/02/2023
Date Signed: 10/02/2023 06:03:07 PM

Document Has Been Signed on 10/02/2023 06:03 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 MEMORY CAREFACILITY NUMBER:
107208996
ADMINISTRATOR:POPE, LINDAFACILITY TYPE:
740
ADDRESS:2145 STANFORD AVETELEPHONE:
(559) 322-8500
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 48CENSUS: 42DATE:
10/02/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:08 PM
MET WITH:Administrator Linda Pope and Health Service Director Keya AlexanderTIME COMPLETED:
06:15 PM
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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 Director Keya Alexander. Residents were observed seating 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: 11/21/22.

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 two dining rooms one on each wing of the facility and an activity room. The outside was toured and observed to be free from debris. There was outdoor seating available for the residents. A sample of staff files were reviewed to have the required documents. A sample of resident’s files were reviewed to have all required documents.

No deficiency cited during inspection.


Exit interview was conducted. LPA received copy of Lic 308, Lic 500, Lic 610E, Administrator certificate, current liability insurance. A copy of this report was provided to the Administrator, whose signature on this form confirm receipt of these reports.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mai Yang
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)
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