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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202563
Report Date: 01/25/2023
Date Signed: 01/25/2023 12:58:05 PM


Document Has Been Signed on 01/25/2023 12:58 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:CASA CARMELFACILITY NUMBER:
275202563
ADMINISTRATOR:O'BRIEN, JOHNFACILITY TYPE:
740
ADDRESS:1000 HACIENDA CARMELTELEPHONE:
(831) 649-3363
CITY:CARMELSTATE: CAZIP CODE:
93923
CAPACITY:6CENSUS: 6DATE:
01/25/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Altamarie Gonzales. TIME COMPLETED:
12:56 PM
NARRATIVE
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On 1/25/2023, Licensing Program Analyst (LPA) K.Kaur arrived unannounced to conduct a case management inspection regarding incident report that were received in the CCL office. Incident Report occurred on 1/16/2023 regarding medication errors. LPA explained reason for inspection and met with Administrator Altamarie Gonzales.

LPA interviewed Administrator. On 1/16/2023 R1 received R2's medication however when discovered incorrect medication was given primary physician was contacted. All emergency procedures were followed by facility following incident. Training for Med Tech was completed.

Deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22,
Division 6.

An exit interview was conducted with Administrator. Report signed on-site and printed copy provided with appeal rights.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023
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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Document Has Been Signed on 01/25/2023 12:58 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710


FACILITY NAME: CASA CARMEL
FACILITY NUMBER: 275202563

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/26/2023
Section Cited

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87465(a)(5) Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed.

This requirement was not met as evidenced by:
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Administrator states that additional training was provided to the Med Tech. Facility has also implemented additional safety procedures to ensure medication errors do not happen.

***POC completed during visit***
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This was not met as evidenced by self reported incidents on 1/16/23 where R1 received R2's medication in error.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -58-4596
LICENSING EVALUATOR NAME: Kamaldeep KaurTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023
LIC809 (FAS) - (06/04)
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