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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270708207
Report Date: 12/13/2023
Date Signed: 12/13/2023 03:52:24 PM


Document Has Been Signed on 12/13/2023 03:52 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710



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:
12/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:DIna Wissinger - AdministratorTIME COMPLETED:
02:50 PM
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On 12/13/2023, Licensing Program Analyst(LPA) D. Ayers arrived unannounced at the facility to conduct a Required Annual Inspection. LPA met with Administrator Designee and announced the purpose of the inspection. Administrator certificate is current with expiration date 8/6/2024.

LPA toured the facility inside and outside. Pathways and doors were clear and free from obstruction. Smoke-detectors and carbon-monoxide detectors were present and operational. Fire extinguisher were recently serviced. Facility was clean and odor free. LPA observed sufficient amount of perishable and non-perishable foodstuffs. Common areas were clean, adequately furnished, and adequately lit. Resident bedrooms were clean and had required minimum furnishings. Resident bathrooms were clean, odor free, and water temperature was within required temperature range. Bathrooms had required non-skid mats and grab bars. Sharp items and detergents were secured in a locked cabinet in the kitchen. Medications were secured in a locked cabinet in the kitchen area, and medications appeared to be administered properly. The fence had a self-locking latch mechanism, and there was adequate outdoor seating for residents. Outdoor area was free from hazards. LPA observed a a supply of clean linens and extra hygiene items for residents. LPA observed sufficient supply of personal protective equipment.
LPA reviewed facility plan of operations and emergency disaster plan. LPA reviewed staff and resident files.
LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan.
No deficiencies were cited during the inspection, exit interview conducted with Licensee, a copy of the report was provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: David AyersTELEPHONE: 559-498-4163
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2023
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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