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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202480
Report Date: 05/24/2021
Date Signed: 05/25/2021 08:04:45 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:CARMELO PARKFACILITY NUMBER:
275202480
ADMINISTRATOR:MAZERIK, MATTHEWFACILITY TYPE:
740
ADDRESS:966 CARMELO STREETTELEPHONE:
(831) 375-0665
CITY:MONTEREYSTATE: CAZIP CODE:
93940
CAPACITY:40CENSUS: 25DATE:
05/24/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Matt MazerikTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Infection Control site visit and met with Matt Mazerik Administrator.

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

Facility observed to have designated entry point for universal symptom screening with questionnaire. All restrooms observed to be supplied with hygiene products. Hand washing signs were posted in bathrooms. Hand sanitizer available to residents. Facility observed to have adequate supply of Personal Protective Equipment (PPE). Staff observed wearing masks.

LPA reviewed the facility policies and procedures to include screening, isolation, disinfecting, staffing, training, supplies, PPE usage and social distancing.

No citations were issued per the California Code of Regulations, Title 22.

LPA reviewed report with Mazerik Administrator and a copy provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021
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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