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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275201286
Report Date: 12/15/2021
Date Signed: 12/17/2021 08:12:22 AM

Document Has Been Signed on 12/17/2021 08:12 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,
, CA
FACILITY NAME:BROOKDALE MANOR OF CARMELFACILITY NUMBER:
275201286
ADMINISTRATOR:CYRIL E. TUPINOFACILITY TYPE:
740
ADDRESS:6385 BROOKDALE DRIVETELEPHONE:
(831) 674-8394
CITY:CARMELSTATE: CAZIP CODE:
93923
CAPACITY: 6CENSUS: 5DATE:
12/15/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Cyril Tupino TIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Marybeth Donovan conducted an unannounced Required - 1 Year Annual Inspection to include Infection Control site visit and met with Cyril Tupino Administrator.

LPA toured the facility inside and out to include entry, kitchen, dining, living room, bedrooms, bathrooms, and exterior. All fire exit routes were free and clear of obstructions. Medications are stored in a locked medication cabinet in the kitchen. Toxins, cleaning supplies, knives and sharp objects are secured.

Facility observed to have designated entry point for COVID 19 symptom screening with questionnaire. Signs posted included Wear a Mask, How to Hand Wash, Symptoms of COVID 19, Droplet Precautions, Contact Precautions, Social Distancing and Lets Keep Our Facility Clean. Bathrooms observed to be supplied with hygiene products. Hand sanitizer available to residents and visitors. LPA observed supply of Personal Protective Equipment (PPE).

LPA reviewed the facility policies and procedures to include screening, visitation, isolation, disinfecting, sick leave polices, training, PPE usage and N95 Fit testing.

No citations issued per the California Code of Regulations Tittle 22.

LPA reviewed report with Cyril Tupino Administrator and a copy of this report provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2021
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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