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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208996
Report Date: 09/04/2024
Date Signed: 09/04/2024 03:34:52 PM


Document Has Been Signed on 09/04/2024 03:34 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
FRESNO RO, 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: 47DATE:
09/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Administrator-Linda PopeTIME COMPLETED:
04:00 PM
NARRATIVE
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On 9/4/2024, Licensing Program Analysts (LPAs) J. Leffall and K.Kaur arrived at the facility unannounced to conduct the Required Annual Inspection. LPAs were greeted by receptionist, stated the purpose of the visit and met with Administrator (A1) Linda Pope. LPA’s conducted tour of facility with A1. Residents were observed, dining area and activity room.

The facility was observed to be at a comfortable temperature, clean, in good repair with no passageway obstructions or fire hazards. Fire extinguisher was observed with a service date of: 11/21/2023. Kitchen was toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in freezer and refrigerator. Refrigerator temperature was observed maintained at 35 degrees F. and freezer was observed maintained at 0 degrees F. Ice machine was observed with yellow discoloring and half of the mechanism had black spots over the yellow discoloration. All chemicals were in locked storage. LPAs toured a sample of resident bedrooms, activity room, dining room and enclosed patio area. Residents' rooms were toured and observed with adequately furnished bed, dresser, and adequate lighting. LPAs observed securely fastened grab bars next to toilet and all tub/shower areas. 6 out of 6 residents rooms observed with non-skid shower strips. 6 out of 6 residents bathroom temperatures measured at 107.4, 106.3, 108.7, 109.3, 105.9, and 106.9 degrees.


LPAs completed a medication audit. Medications were stored in a locked medication room in a medication cart. MARs and medications were reviewed. Review of Centrally Stored Medication Record revealed R1’s medication log was incomplete. Based on record review LPAs observed 1 out of 1 residents medication count was over the required amount. 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.

Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22,Division 6.



An exit interview was conducted with Licensee. Report signed on-site; a copy of this report, 809D with appeal rights was provided.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) 580-4596
LICENSING EVALUATOR NAME: Jacques LeffallTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024
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


Document Has Been Signed on 09/04/2024 03:34 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: CARMEL VILLAGE MEMORY CARE
FACILITY NUMBER: 107208996

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(29)
General Food Service Requirements
(b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, Ice machine was observed with yellow discoloring and half of the mechinism had black spots over the yellow discoloring, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2024
Plan of Correction
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Licensee agrees to clean/sanitize ice machine and submit photo of clean white mechinism to to CCLD.
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 1 medication R1's medication count was over the required amount which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2024
Plan of Correction
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Administrator agrees to submit inservice medication training completion forms to CCLD.
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) 580-4596
LICENSING EVALUATOR NAME: Jacques LeffallTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 09/04/2024 03:34 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: CARMEL VILLAGE MEMORY CARE
FACILITY NUMBER: 107208996

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation interview, record review Centrally Stored Medication Record was incomplete, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/05/2024
Plan of Correction
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Administrator agrees to submit inservice medication training completion forms to CCLD.
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) 580-4596
LICENSING EVALUATOR NAME: Jacques LeffallTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 09/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/04/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3