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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275294324
Report Date: 08/31/2022
Date Signed: 08/31/2022 11:16:48 AM


Document Has Been Signed on 08/31/2022 11:16 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



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: 9DATE:
08/31/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:32 AM
MET WITH:Michael HagertyTIME COMPLETED:
11:35 AM
NARRATIVE
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On 8/31/2022, Licensing Program Analysts (LPA) M. Medina conducted a Case Management based on observations made during an unrelated Complaint Investigation.

Facility toured. During the course of complaint investigation conducted, staff files were reviewed, LPA observed no training documents on file since 2019 or proof of first aid of first aid for S#1. Training records for staff #2 are incomplete. Facility sketch has changed and has not been reported to department.

Deficiencies cited on the attached 809-D.

Exit interview conducted. A copy of this report was provided for facility records.
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SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 08/31/2022 11:16 AM - 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, 1314 E SHAW AVE
FRESNO, CA 93710


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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2022
Section Cited

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All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69
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**This was not evidenced by no training documents on file since 2019 or proof of first aid of first aid for S#1. Training records for staff #2 are incomplete.
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Type B
09/09/2022
Section Cited

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(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any
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significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:(7) Sketches, showing dimensions.
**This was not met as evidenced by facility has added a building in back yard, use of rooms in facility has changed.
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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: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2