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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270700110
Report Date: 11/01/2024
Date Signed: 11/02/2024 06:32:24 AM

Document Has Been Signed on 11/02/2024 06:32 AM - 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 VALLEY MANORFACILITY NUMBER:
270700110
ADMINISTRATOR/
DIRECTOR:		CHRIS REGANFACILITY TYPE:
741
ADDRESS:8545 CARMEL VALLEY ROADTELEPHONE:
(831) 624-1281
CITY:CARMELSTATE: CAZIP CODE:
93923
CAPACITY: 258TOTAL ENROLLED CHILDREN: 0CENSUS: 199DATE:
11/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:02 AM
MET WITH:Administrator Chris ReganTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 11/01/2024, Licensing Program Analyst (LPA) V Gorban arrived at the facility unannounced to conduct Required Annual Inspection. LPA met with Administrator (AD) Chris Regan, certification number 6051485740 and expiration date 02/25/2025. LPA conducted tour inside and out of facility with AD. Residents observed at the facility during lunch.

The facility was observed to be at a comfortable temperature of 76 degrees, clean, in good repair, and no passageway obstructions or fire hazards observed. Fire extinguisher was observed with a service date of 07/30/2024

Dining area and Kitchen were toured. An adequate supply of perishable and non-perishable food was observed to be properly stored in freezer, refrigerator, and pantry. Food is delivered once a week on Thursdays. Refrigerator temperature was maintained at 40.0-degree F. and freezer was maintained at -2-degree F.

Residents' rooms were toured and observed with adequately furnished with bed, dresser, and adequate lighting. Hot water temperature tested at 112 degrees F. LPA observed securely fastened grab bar and non-skid mat in shower area.

Medications were stored in a locked medication room in a medication cart. Medications records were reviewed. First Aid Kit was stored in medication room and observed with all required items. Adequate PPE supplies was observed. LPA toured laundry room and observed chemicals were stored and locked for staff use only.

Facility courtyard was toured and observed to be free from debris. There was outdoor seating available for the residents.
Brenda ChanTELEPHONE: (650) 266-8889
Vadim GorbanTELEPHONE: (559) 243-8080
DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: CARMEL VALLEY MANOR
FACILITY NUMBER: 270700110
VISIT DATE: 11/01/2024
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A sample of residents’ file was reviewed to have updated emergency contact, Admission agreement, Needs and Services Plan and Pre-Appraisal Plan. A sample of staff files were reviewed. Staff files were observed to have current First Aid/CPR, Health screening, and Personnel record. Staff are fingerprinted clear and associated to the facility.

Community Care Licensing (CCL) is always striving to have facility files that reflect the most accurate & up to date information for your facility. In an effort to maintain your facility file, please submit the most current & complete forms &/or information as identified below:

Residential Care Facility for the Elderly (RCFE):


· LIC 308 Designation of Facility Responsibility
· LIC 309 Administrative Organization
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
· LIC 9020 Register of Facility Clients/Residents


Please submit the above forms/information to Fresno CCL by: 11/04/2024

As an operator of a Community Care Licensed facility it is your responsibility to be aware of and in compliance with all regulations, including Chaptered Legislation. Go to www.ccld.ca.gov to stay updated and informed.


No deficiencies issued during this inspection. An exit interview was conducted with the ED.

A copy of this report was given to the ED, whose signature on this form confirm receipt of these reports.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2024
LIC809 (FAS) - (06/04)
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