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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270708207
Report Date: 12/15/2021
Date Signed: 12/17/2021 08:10:45 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 VILLAFACILITY NUMBER:
270708207
ADMINISTRATOR:KATHLEEN S. VORISFACILITY TYPE:
740
ADDRESS:26635 PANCHO WAYTELEPHONE:
(831) 625-9394
CITY:CARMELSTATE: CAZIP CODE:
93923
CAPACITY:6CENSUS: 6DATE:
12/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Dina WissengerTIME COMPLETED:
01:15 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 Dina Wissinger Assistant Administrator.

LPA toured the facility inside and out to include entry, kitchen, dining, living room, bedrooms, bathrooms, and exterior. All fire exit routes were free and clear of obstructions. Medications are stored in a locked cabinet in the kitchen. Toxins, cleaning supplies, knives and sharp objects are secured.

Facility observed to have designated entry point for COVID 19 symptom screening with questionnaire. Signs posted included Visitor policy, Mask Policy, Wear a Mask, Wash Your Hands, and Cough and Cover. Bathrooms observed to be supplied with hygiene products and Hand washing signs posted as well. Hand sanitizer available to residents and visitors. LPA observed supply of Personal Protective Equipment (PPE).

LPA reviewed the facility policies and procedures to include screening, visitation, isolation, disinfecting, sick leave polices, training, and PPE usage.

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

LPA reviewed report with Dina Wissienger Assistant 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: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2021
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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