<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275201906
Report Date: 12/23/2022
Date Signed: 12/29/2022 01:34:16 PM

Document Has Been Signed on 12/29/2022 01:34 PM - 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: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: 6DATE:
12/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Admininstrator, Charito SerranoTIME COMPLETED:
12:18 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/23/2022, Licensing Program Analysts (LPA) V. Gorban arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by Administrator, Charito Serrano, certificate expiration on 10/26/2022.

Visitor log-in/temperature check station was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Hand washing and other various Covid-19 related signs were observed in the common areas. Facility staff was observed with mask covering.

The facility was observed to be at a comfortable temperature, free of debris, in good repair, and no passageway obstructions or fire hazards were observed. Common areas were properly furnished and well-lit throughout. PPE were observed in a laundry room. A 2-day supply of perishable and 7-day supply of non-perishable food was observed to be properly stored and labelled. Fire extinguisher was observed with a service date of 09/13/2022. Resident's all 6 bedrooms were observed to be adequately furnished with bed, dresser, and adequate lighting. Sample of residents file was reviewed for emergency contact.

No deficiencies were observed. Administrator was provided the source to Title 22 and PINs update information.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE: DATE: 12/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2022
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: VILLA MIRAGE OF CARMEL
FACILITY NUMBER: 275201906
VISIT DATE: 12/23/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LPAs are requesting the following documents to be provided to the Fresno CCL office by 01/27/2023: Current copy
Of:

LIC 308 Designation of Facility Responsibility
· -as applicable: LIC 309 Administrative Organization
· -as applicable: LIC 400 Affidavit Regarding Client/Resident Cash Resources
· -as applicable: LIC 402 Surety Bond
· LIC 500 Personnel Report
· LIC 610E Emergency Disaster Plan For Residential Care Facilities For The Elderly
· LIC 9020 Register of Facility Clients/Residents
· Copy of current Liability Insurance
· Copy of current Administrator Certificate
· Alternate contact information including name, telephone number, & email address.


An exit interview was conducted with Administrator. Report signed on-site by Administrator and printed copy provided.
SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Vadim Gorban
LICENSING EVALUATOR SIGNATURE:

DATE: 12/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/23/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2