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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275201286
Report Date: 12/04/2025
Date Signed: 12/05/2025 08:40:39 AM

Document Has Been Signed on 12/05/2025 08:40 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
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:BROOKDALE MANOR OF CARMELFACILITY NUMBER:
275201286
ADMINISTRATOR/
DIRECTOR:		CYRIL E. TUPINOFACILITY TYPE:
740
ADDRESS:6385 BROOKDALE DRIVETELEPHONE:
(831) 674-8394
CITY:CARMELSTATE: CAZIP CODE:
93923
CAPACITY: 6CENSUS: 6DATE:
12/04/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:administrator Julie GaleanoTIME VISIT/
INSPECTION COMPLETED:
05:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) V Gorban conducted an unannounced visit today for the facility’s annual inspection. LPA met with administrator Julie Galeano, stated the purpose of the visit and as allowed entry in to the facility.
There are currently 6 residents who reside at this home and there are two of them with dementia diagnose. LPA inspected the interior and the exterior of the facility including the common living spaces, resident bedrooms and bathrooms, medication storage in the kitchen, garage and outdoor areas. Bedrooms were clean and in good repair. There is a locked storage for medications. Food supply is adequate for 2-day perishable and 7-day nonperishable.

Fire extinguisher service date recorded on 12/2/2025 with emergency fire drill recorded in December, 2024 . Smoke alarms were tested and are operational. The home has a carbon monoxide detector. Water temperature was tested at 110 degrees. First Aid kit is on site.
LPA reviewed facility Plan of Operations, Infection Control Plan, and Emergency Disaster Plan. LPA reviewed facility staff files, and 4 facility resident files.

Resident 2 has expired medical assessment. Incomplete Plan Of Operations, Infection Control , And Emergency Disaster Plan. Resident 2 does not have annually updated needs and services plan. Emergency Disaster Plan needs to be updated and more specific/updated. Infection Control Plan needs to be more specific/updated. Staff missing required files. Facility does not have Plan of Operation available for review.
The following deficiencies observed or cited during today's inspection per California Code of Regulations, Title 22.
Exit interview conducted with administrator, report signed and copy of this report with appeal rights provided for facility records.
NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: Vadim Gorban
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2025
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 12/05/2025 08:40 AM - It Cannot Be Edited


Created By: Vadim Gorban On 12/04/2025 at 03:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BROOKDALE MANOR OF CARMEL
FACILITY NUMBER: 275201286

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(b)
Other Provisions
(b) At least one administrator, facility manager, or designated substitute who is at least 21 years of age and has qualifications adequate to be responsible and accountable for the management and administration of the facility pursuant to Title 22 of the California Code of Regulations shall be on the premises 24 hours per day. The designated substitute may be a direct care staff member who shall not be required to meet the educational, certification, or training requirements of an administrator. The designated substitute shall meet qualifications that include, but are not limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in facility failed to comply and ensure certified administrator present at the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2025
Plan of Correction
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Administrator will submit update / anticipated date to admin training completion to LPA by POC date of 12/12/2025.
Type B
Section Cited
CCR
87470(a)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in facility residents do not have updated Infection control Plan, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2025
Plan of Correction
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Administrator will submit update Infection Control to LPA by POC date of 12/12/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Vadim Gorban
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2025


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 12/05/2025 08:40 AM - It Cannot Be Edited


Created By: Vadim Gorban On 12/04/2025 at 03:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BROOKDALE MANOR OF CARMEL
FACILITY NUMBER: 275201286

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)
Plan of Operation
(a) The licensee shall have and maintain a current, written definitive plan of operation for the facility. The licensee shall operate the facility in accordance with the terms specified in the plan of operation and may be cited for not doing so pursuant to Health and Safety Code section 1569.49. 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 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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in facility missing definitive Plan of Opearations, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2025
Plan of Correction
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Administrator will review and update Plan of Operations by POC date of 12/12/2025.
Type B
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in facility leaving cleaning supplies/desinfectant accesible to residents with dementia diagnose, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2025
Plan of Correction
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Administrator will submit plan of corrections to LPA by POC date of 12/12/2025.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Vadim Gorban
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 12/05/2025 08:40 AM - It Cannot Be Edited


Created By: Vadim Gorban On 12/04/2025 at 03:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BROOKDALE MANOR OF CARMEL
FACILITY NUMBER: 275201286

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/04/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in facility staff missing staff records including current CPR and first aid certificate/ classes , which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2025
Plan of Correction
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Administrator will ensure employee records updated by POC date of 12/12/2025.
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.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
Vadim Gorban
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/04/2025


LIC809 (FAS) - (06/04)
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