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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202480
Report Date: 05/07/2024
Date Signed: 05/17/2024 09:04:03 AM


Document Has Been Signed on 05/17/2024 09:04 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:CARMELO PARKFACILITY NUMBER:
275202480
ADMINISTRATOR:MAZERIK, MATTHEWFACILITY TYPE:
740
ADDRESS:966 CARMELO STREETTELEPHONE:
(831) 375-0665
CITY:MONTEREYSTATE: CAZIP CODE:
93940
CAPACITY:40CENSUS: 26DATE:
05/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Matthew Mazerik - AdministratorTIME COMPLETED:
11:40 AM
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On 5/7/2024, Licensing Program Analyst(LPA) D. Ayers arrived unannounced at the facility to conduct a Required Annual Inspection. LPA met with Administrator Matthew Mazerik and announced the purpose of the inspection. There were 5 residents on hospice at the time of the inspection.

LPA toured the facility inside and outside. Pathways and exits were clear and free from obstruction. Smoke-detectors and carbon-monoxide detectors were present and operational. Fire extinguishers had been recently serviced. Outdoor areas were free from hazards and provided sufficient seating for residents. Medications were properly secured and appeared to be administered properly. Sharp items and cleaning supplies were secured and not accessible to residents. Facility was clean and LPA observed a sufficient supply of perishable and nonperishable food stuffs which were properly stored.
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. The facility employs an Activities Coordinator, and LPA observed facility schedule of planned activities and monthly meal menu.
LPA reviewed facility plan of operations and emergency disaster plan. LPA reviewed a sample of resident and staff files, which contained all required records.
LPA requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, 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: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024
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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