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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275294324
Report Date: 04/24/2022
Date Signed: 04/24/2022 01:34:06 PM


Document Has Been Signed on 04/24/2022 01:34 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
CCLD Regional Office,
, CA



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: 5DATE:
04/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Michael HagertyTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Sarah Hurt conducted an unannounced visit April 24, 2022 at 9:00 a.m. for the facility’s annual inspection. LPA met with Administrator Michael Hagerty, Continual Administrator's Certification expires 09/03/2023. There are currently 5 residents who reside at this home and there is 3 residents on hospice at this time. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, medication storage, kitchen, and outdoor areas. Bedrooms were clean and in good repair. LPA observed sufficient supply of bedding linens in facility closet. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed resident as needed PRN medications not being logged in Medication Administration Record.

Fire extinguisher is within the safety regulation period. Smoke alarms were tested and are operational. The home has a carbon monoxide detector and performs disaster drills as required. Water temperature was tested at 109 degrees. First Aid kit is on site and complete. Toxins and cleaning supplies are locked and inaccessible. LPA observed all staff working is background cleared. LPA reviewed staff files and all have vaccine exemption forms or vaccination records.

The following deficiencies were cited during today's inspection per California Code of Regulations, Title 22.

LPA's requested the following documents: LIC 500 Personnel Report, LIC 308 Designation of Administrative Responsibility, LIC 610-E the Emergency Disaster Plan and copy of current Administrator’s Certificate to update the facility file. Listed documents shall be sent to Licensing.

Exit interview conducted with Administrator Michael Hagerty and copy of report left at facility
SUPERVISOR'S NAME: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2022
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 04/24/2022 01:34 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
CCLD Regional Office,
, CA


FACILITY NAME: FLANDERS COURT OF CARMEL, LLC
FACILITY NUMBER: 275294324

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(3)

87465(C) Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident in unable to determine his or her own need for nonprescription PRN medication but communicate his/her symptoms clearly, facility staff designated by the licensee shall permitted to assist the resident with self - administration, provided all of the following requirements are met. (3) A record of each dose is maintained in residents records. The record shall include the date and time the PRN medication was taken, the dosage taken and the residents response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section as LPA observed PRN medications not being logged into residents records which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/10/2022
Plan of Correction
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Administrator will submit proof of logging PRN's into Medication Administration Record to LPA by 05/10/2022 POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Stephenie DoubTELEPHONE: (916) 263-2131
LICENSING EVALUATOR NAME: Sarah HurtTELEPHONE: (916) 879-2602
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2022
LIC809 (FAS) - (06/04)
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