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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275294324
Report Date: 12/15/2020
Date Signed: 12/22/2020 09:40:05 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131
FACILITY NAME:FLANDERS COURT OF CARMEL, LLCFACILITY NUMBER:
275294324
ADMINISTRATOR:HAGERTY, MICHAELFACILITY TYPE:
740
ADDRESS:25661 MORSE DRIVETELEPHONE:
(831) 626-0824
CITY:CARMELSTATE: CAZIP CODE:
93923
CAPACITY:6CENSUS: 6DATE:
12/15/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Michael HagertyTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted a Technical Assist (TA) Visit via FaceTime platform with Michael Hagerty Administrator and Janet Hayes, BSN, RN California Department of Public Health. The purpose of the visit was to provide technical assistance For Infection Prevention and Control guidelines for Adult and Senior Care facilities. LPA conducted a virtual tour of the facility.

The following recommendations were discussed:

1. Clean shaven men for properly N95 seal
2. Follow up with second round of mass testing
3. Try to prevent crossover of staff between two houses
4. Follow up with holiday recommendations with staff and residents

Informational Links and websites were provided to include Tying the Face Mask, PPE Burn Calculator, PPE Eye Protection, UCSF Donning/Doffing PPE, Seal Check for N95 Mask, Return to Work, Cleaning, Testing and Holiday Guidance.

Report reviewed with Michael Hagerty and copy emailed for signature purposes.
SUPERVISOR'S NAME: George NwaforTELEPHONE: (650) 269-7419
LICENSING EVALUATOR NAME: Marybeth DonovanTELEPHONE: (408) 726-4301
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE:
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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