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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202260
Report Date: 06/29/2023
Date Signed: 06/29/2023 11:14:34 AM


Document Has Been Signed on 06/29/2023 11:14 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:ARCHWAY OF CARMELFACILITY NUMBER:
275202260
ADMINISTRATOR:CYRIL TUPINOFACILITY TYPE:
740
ADDRESS:3262 TAYLOR ROADTELEPHONE:
(831) 269-4164
CITY:CARMELSTATE: CAZIP CODE:
93923
CAPACITY:6CENSUS: 5DATE:
06/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Maria Carrillo - Lead CaregiverTIME COMPLETED:
11:30 AM
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On 6/29/2023, Licensing Program Analyst(LPA) D. Ayers arrived unannounced at the facility to conduct a Required Annual Inspection. LPA met with lead Caregiver Maria Carrillo and spoke with Licensee Cyril Tupino via telephone. Administrator certificate was current with expiration date 10/28/2023. There were 2 residents on hospice at the time of the inspection.

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. 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. Sharp items and detergents were secured in a locked cabinet in the kitchen. A locked cabinet in the garage was observed to store resident medications, and medications appeared to be administered properly. The fence had a self-locking latch mechanism, and there was adequate outdoor seating for residents. LPA reviewed facility plan of operations and emergency disaster plan. LPA reviewed resident files: staff files will be reviewed on another date.
LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan, and a copy of current Administrator’s Certificate to update the facility file.
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: 06/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2023
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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