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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 275294324
Report Date: 08/31/2022
Date Signed: 08/31/2022 10:31:08 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/08/2022 and conducted by Evaluator Melinda Medina
COMPLAINT CONTROL NUMBER: 24-AS-20220808120217
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
UNANNOUNCEDTIME BEGAN:
07:27 AM
MET WITH:Herman Fickewirth
Michael Hagerty 		TIME COMPLETED:
10:28 AM
ALLEGATION(S):
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Facility is over ratio
Resident is locked in room
INVESTIGATION FINDINGS:
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On 8/31/2022, Licensing Program Analyst (LPA) M. Medina conducted a subsequent complaint visit. LPA introduced self, stated purpose of visit, and allowed entrance into facility. LPA met with Licensee, Herman Fickerwirth and Administrator, Michael Hagerty.

LPA Medina toured entire facility with Licensee and Administrator. LPA observed that there are currently 9 residents residing in facility of which 3 are identified as independent living. LPA observed 2 bedrooms (R1 & R2) to have exit doors being blocked.

Based on LPA observation and interviews, the preponderance of evidence standard has been met therefore the allegation is found to be substantiated. Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D.

An immediate civil penalty of $500 is assessed.

An exit interview was conducted with Michael Hagerty, Administrator. A copy of this report and appeal rights were discussed and provided.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 24-AS-20220808120217
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 A
09/01/2022
Section Cited
CCR
87204(a)
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Limitations - Capacity and Ambulatory Status (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may
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Licensee to submit written plan by POC due date to bring facility into compliance. Licensee/Administrator to continue to work with APS to find suitable housing to meet resident needs. Licensee/Administrator to
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receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.
**This was not met as evidenced by LPA observed 9 residents currently in facility of which 3 are identified as Independent Living.
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contact Department no later than 9/30/22 with updates and relocation information for residents.
Type A
09/01/2022
Section Cited
CCR
87468.1
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Personal Rights of Residents in All Facilities a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(1) To be accorded dignity in their
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Licensee to move items blocking doors in R1 & R2 bedrooms and ensure they remain clear
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personal relationships with staff, residents, and other persons.

**This was not met as evidenced by LPA observed 2 bedrooms (R1 & R2) to have exit doors being blocked.
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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
LIC9099 (FAS) - (06/04)
Page: 2 of 2