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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275201906
Report Date: 12/16/2021
Date Signed: 12/17/2021 08:15:47 AM

Document Has Been Signed on 12/17/2021 08:15 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:VILLA MIRAGE OF CARMELFACILITY NUMBER:
275201906
ADMINISTRATOR:SERRANO, CHARITO M.FACILITY TYPE:
740
ADDRESS:101 VILLAGE LANETELEPHONE:
(831) 659-5689
CITY:CARMEL VALLEYSTATE: CAZIP CODE:
93924
CAPACITY: 6CENSUS: 5DATE:
12/16/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Charito SerranoTIME COMPLETED:
11:30 AM
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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 Charito Serrano Administrator.

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

Facility observed to have designated entry point for universal symptom screening and temperature check. All bathrooms observed to be supplied with hygiene products and hand washing signs were posted. Hand sanitizer available to residents throughout the facility. LPA observed supply of Personal Protective Equipment (PPE). Regional office will provide additional PPEs to the facility.

LPA reviewed the facility Mitigation Plan, policies and procedures to include screening, visitation, isolation, disinfecting, training, PPE supplies and usage.

No citations were issued per the California Code of Regulations, Title 22.

LPA reviewed report with Charito Serrano Administrator and a copy provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Marybeth Donovan
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2021
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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