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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208996
Report Date: 02/06/2025
Date Signed: 02/06/2025 01:02:59 PM

Document Has Been Signed on 02/06/2025 01:02 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:CARMEL VILLAGE MEMORY CAREFACILITY NUMBER:
107208996
ADMINISTRATOR/
DIRECTOR:		POPE, LINDAFACILITY TYPE:
740
ADDRESS:2145 STANFORD AVETELEPHONE:
(559) 322-8500
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 48TOTAL ENROLLED CHILDREN: 0CENSUS: 41DATE:
02/06/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Administrator: Linda PopeTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On 2/6/25, Licensing Program Analyst (LPA) J. Leffall conducted a case management visit to follow up and confirm details of an incident report that was received by the Department. The incident occurred on 1/22/25, in which Resident’s personal rights were violated during meal time at facility. An internal investigation was conducted and it was concluded that Staff (S1) and (S2) were adjusting resident’s meals.

Per LIC-624 the facility completed a termination of S1 and S2. The document with Plan of Correction (POC), Mandated Reporting protocol (AB-1417 (2023), Resident Rights in Assisted Living, and Managing Malnutrition and Dehydration forms were submitted to CCLD.

A citation is issued on the attached 809-D regarding client’s Personal Rights.
See MouaTELEPHONE: (559) 580-4596
Jacques LeffallTELEPHONE: 559-243-8080
DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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 2
Document Has Been Signed on 02/06/2025 01:02 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
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: 02/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/07/2025
Section Cited
CCR
87468.2

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities

(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:

(5) To be served food of the quality and quantity necessary to meet their nutritional needs.

This requirement was not met as evidenced by the facility’s report and investigation that 2 staff scrapped food off resident’s plate prior to serving them, which poses a potential health, safety, and personal rights risk.

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Licensee agrees to terminate the 2 Caregiver employees for violating residents’ personal rights. Notify resident’s RP’s who reside on South Hallway who were potentially impacted by the violation incident. Conduct Inservice training that includes:

-Generations MC Dining Room Policy and Procedures
-Resident Personal Rights
-Mandated Reporter Expectations
-Managing Mealtime with Dementia

Enroll all MC Caregivers and MC med aides in the following Relias Courses. They include:

-Abuse, Neglect, and Exploitation in the Elder Care Setting
-Resident Rights in Assisted Living
-Managing Malnutrition and Dehydration

Continue to monitor and document the monthly weight of all residents. Notify MD per policy of weight changes month-over-month.

Supervisor(s) will randomly monitor dining room activity; goal is to validate training is now a BEST PRACTICE(S)


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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.
See MouaTELEPHONE: (559) 580-4596
Jacques LeffallTELEPHONE: 559-243-8080

DATE: 02/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2025

LIC809 (FAS) - (06/04)
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