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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700110
Report Date: 11/18/2021
Date Signed: 11/19/2021 06:04:15 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:CARMEL VALLEY MANORFACILITY NUMBER:
270700110
ADMINISTRATOR:CHRIS REGANFACILITY TYPE:
741
ADDRESS:8545 CARMEL VALLEY ROADTELEPHONE:
(831) 624-1281
CITY:CARMELSTATE: CAZIP CODE:
93923
CAPACITY:258CENSUS: 184DATE:
11/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Pam Ziering and Chris ReganTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Pam Ziering Assisted Living Manager and Chris Regan Health Services Administrator.

LPA toured the facility inside and out. All fire exit routes were free and clear of obstructions. Medications are stored in a locked medication room. Toxins, cleaning supplies, knives and sharp objects are secured.

Facility observed to have designated entry point for COVID 19 symptom screening with questionnaire. LPA reviewed Staff and Visitor Screening Log, COVID 19 Daily Staff Log, Resident Daily Temperature Log, Residents Emergency Information, Staff Communication Log and Emergency Disaster Plan. Bathrooms observed to be supplied with hygiene products and hand washing signs posted. In addition, other signs included How to Wear a Mask, Droplet Precautions, and COVID 19 Symptoms. Educational Video displayed providing infectious disease prevention and mitigation practices. Hand sanitizer stations available throughout the facility. LPA observed supply of Personal Protective Equipment (PPE). All staff are N95 Fit Tested.

LPA reviewed Provider Information PIN 21-49-ASC dated November 17.2021, Subject Updated Guidance on communal dining, group activities, entertainment, non-essential services and transportation with Pam Ziering Assisted Living Manager and Chris Regan Health Services Administrator.

No citations issued per the California Code of Regulations Tittle 22.

LPA reviewed report with Pam Ziering Assisted Living Manager and Chris Regan Health Services Administrator and a copy of this report provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
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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