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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 270708749
Report Date: 01/04/2023
Date Signed: 01/05/2023 10:33:52 AM


Document Has Been Signed on 01/05/2023 10:33 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:MAGNOLIA MANOR OF CARMELFACILITY NUMBER:
270708749
ADMINISTRATOR:PEACH, VICTORIAFACILITY TYPE:
740
ADDRESS:26695 PANCHO WAYTELEPHONE:
(831) 625-9488
CITY:CARMELSTATE: CAZIP CODE:
93923
CAPACITY:6CENSUS: 0DATE:
01/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administsrator, Victoria Peach TIME COMPLETED:
11:00 AM
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On 01/04/2023, Licensing Program Analyst (LPA) V Gorban arrived at the above facility to conduct a case management - closure inspection. The purpose of the inspection is for a voluntary closure. LPA introduced self, stated the purpose of the visit, and met with Licensee Victoria Peach. Licensee notified LPA and Department in October 10 of 2022 about facility closure.

LPA conducted a final tour with License and observed all Residents have been removed and relocated. Licensee surrendered her RCFE license on the previous visit from another department. Closure inspection is complete.

No deficiencies issued.

An exit interview was conducted with Licensee. Report signed on site and printed copy provided. Facility closure will be processed upon LPA’s return to the office.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Vadim GorbanTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 01/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2023
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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