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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275201906
Report Date: 10/22/2025
Date Signed: 10/22/2025 08:29:01 PM

Document Has Been Signed on 10/22/2025 08:29 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:VILLA MIRAGE OF CARMELFACILITY NUMBER:
275201906
ADMINISTRATOR/
DIRECTOR:		SERRANO, CHARITO M.FACILITY TYPE:
740
ADDRESS:101 VILLAGE LANETELEPHONE:
(831) 659-5689
CITY:CARMEL VALLEYSTATE: CAZIP CODE:
93924
CAPACITY: 6CENSUS: 6DATE:
10/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:30 PM
MET WITH:Administrator: Charito SerranoTIME VISIT/
INSPECTION COMPLETED:
09:00 PM
NARRATIVE
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On 10/22/25 Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was greeted by Staff (S1) Maria Resendiz. LPA was granted entry. All 6 residents were present during inspection. Administrator Charito Serrano (A1) was called and arrived shortly after LPA’s arrival.

LPA toured facility with S1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Freezer temperature was maintained at -20 degrees F and refrigerator temperature was maintained at 30 degrees F. Fire extinguisher was observed with a purchase date of: 10/110/24. No Fire drill conducted quarterly. Washer and dryer observed operational during visit. Carbon monoxide not observed in the facility. Smoke detectors were tested and observed to be operational. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested at a range of 106 degrees F and 119.4 degrees F in bathroom 3 out of 4 bathrooms. Bathroom 2 water temperature tested at 124.8 degrees F. Non-skid mat and grab bars observed in bathrooms. Outside of facility toured. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for residents. All medications were checked and observed kept locked in the hall closet. Residents’ MARS was reviewed. First aide kit observed with all of the required items. Both resident’s and staff files had multiple missing documents.

Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6.


Exit Interview conducted. The following documents requested to be updated and submitted to Fresno CCL by 11/5/25: Lic 308, Lic 500, Lic 610E, Current Liability Insurance and current Administrator’s certificate. A copy of this report was provided to Administrator, whose signature on this form confirms receipt of these report.

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Jacques Leffall
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2025
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 10
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)
Page: 2 of 10
Document Has Been Signed on 10/22/2025 08:29 PM - It Cannot Be Edited


Created By: Jacques Leffall On 10/22/2025 at 07:34 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: VILLA MIRAGE OF CARMEL
FACILITY NUMBER: 275201906

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.33(h)
Regulations
(h) As a part of the department’s evaluation process, the department shall review the plan of operation, training logs, and marketing materials of any residential care facility for the elderly that advertises or promotes special care, special programming, or a special environment for persons with dementia to monitor compliance with Sections 1569.626 and 1569.627.

This requirement is not met as evidenced by:
Deficient Practice Statement
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3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 out of 2 fire extinguishers are past the one year service/purchase date which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2025
Plan of Correction
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2
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4
LIcensee agrees to either purchase new fire extinguishers or have the ones in the facility serviced with service tags. Licensee agrees to submit receipts of new fire extinguishers or pictures of service tags that are updated to CCLD by POC due date.
Type A
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 1 Carbon Monoxide Dectectors missing in facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2025
Plan of Correction
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2
3
4
Licensee agrees to purchase a Carbon Monoxide Detector and send photo of the new Detector or copies of receipt and submit to CCLD by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Jacques Leffall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2025


LIC809 (FAS) - (06/04)
Page: 3 of 10
Document Has Been Signed on 10/22/2025 08:29 PM - It Cannot Be Edited


Created By: Jacques Leffall On 10/22/2025 at 07:34 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: VILLA MIRAGE OF CARMEL
FACILITY NUMBER: 275201906

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 4 water faucets were tested at a temperature of 124.8 in bathroom 2 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2025
Plan of Correction
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Licensee agrees to have water heater repaired or replaced. Licensee agrees to test water temperature in bathroom 2 and must meet temperature regulation ranging from 105 degrees F to 120 degrees F, and send photo to CCLD by POC due date.
Type A
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 observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 2 staff is not First Aide certified which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2025
Plan of Correction
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Licensee agrees to have staff complete First Aide training and submit completion document/certificate to CCLD by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Jacques Leffall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2025


LIC809 (FAS) - (06/04)
Page: 4 of 10
Document Has Been Signed on 10/22/2025 08:29 PM - It Cannot Be Edited


Created By: Jacques Leffall On 10/22/2025 at 07:34 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: VILLA MIRAGE OF CARMEL
FACILITY NUMBER: 275201906

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)(2)
(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: (2) A copy of the Admission Agreement, containing basic and optional services.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 5 residents does not have an Admission Agreement which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2025
Plan of Correction
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LIcensee agrees to complete the Admission Agreement for Resident (R1) and submit copy to CCLD by POc due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Jacques Leffall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2025


LIC809 (FAS) - (06/04)
Page: 5 of 10
Document Has Been Signed on 10/22/2025 08:29 PM - It Cannot Be Edited


Created By: Jacques Leffall On 10/22/2025 at 07:34 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: VILLA MIRAGE OF CARMEL
FACILITY NUMBER: 275201906

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87406(a)(1)(B)
Administrator Certification Requirements
(a) All individuals shall be residential care facility for the elderly certificate holders prior to being employed as an administrator. (1) Applicants who possess a valid Nursing Home Administrator license, issued by the California Department of Public Health, shall be exempt from completing an approved Initial Certification Training Program and taking a written exam, provided the individual completes twelve (12) hours of classroom instruction in the following Core of Knowledge areas: (B) Four (4) hours of instruction in medication management, including the use, misuse, and interaction of drugs commonly used by the elderly, including antipsychotics, and the adverse effects of psychotropic drugs for use in controlling the behavior of persons with dementia.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 2 staff does not possess a certificate in medication training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2025
Plan of Correction
1
2
3
4
Licensee agrees to have staff complete medication training and submit completion document to CCLD by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Jacques Leffall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2025


LIC809 (FAS) - (06/04)
Page: 6 of 10
Document Has Been Signed on 10/22/2025 08:29 PM - It Cannot Be Edited


Created By: Jacques Leffall On 10/22/2025 at 07:34 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: VILLA MIRAGE OF CARMEL
FACILITY NUMBER: 275201906

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(10)
Resident Records
(b) Each resident's record shall contain at least the following information: (10) Reports of the medical assessment specified in Section 87458 Medical Assessment, and of any special problems or precautions.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 out of 5 residents does not possess an LIC-602 with TB test, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2025
Plan of Correction
1
2
3
4
LIcensee agrees to have residents visit Dr. and have Dr. complete an LIC-602 with TB test and submit completed LIC-602's to CCLD by POC due date.
Type B
Section Cited
CCR
87506(b)(16)
Resident Records
(b) Each resident's record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in 2 out of 5 residents do not possess a Safeguard for Property Values which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2025
Plan of Correction
1
2
3
4
Licensee agrees to complete the Safeguard for Property Values forms and submit to CCLD by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Jacques Leffall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2025


LIC809 (FAS) - (06/04)
Page: 7 of 10
Document Has Been Signed on 10/22/2025 08:29 PM - It Cannot Be Edited


Created By: Jacques Leffall On 10/22/2025 at 07:34 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: VILLA MIRAGE OF CARMEL
FACILITY NUMBER: 275201906

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)(2)
Reappraisals
(c) If the licensee observes or is made aware of behavioral expression, as defined in Section 87101, that has caused or may cause harm to the resident or others, the licensee shall document all of the following in the resident’s reappraisal: (2) If known, identification of events occurring just prior to the behavioral expression including, but not limited to, interactions with other residents or staff, sudden or recent changes in the physical environment, signs of possible new physical illness or injury (such as fever, cough, urinary urgency, or limping), overstimulation (such as from noise or visitors), or physical sensations a resident may not be able to express verbally that may include, but are not limited to, fatigue, heat, cold, pain, hunger, thirst, boredom, fear, wanting to walk, or need for toileting.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 5 residents does not possess an LIC-601 in resident file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2025
Plan of Correction
1
2
3
4
Licensee agrees to complete the LIC-601 and submit to CCLD by POC due date.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Jacques Leffall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2025


LIC809 (FAS) - (06/04)
Page: 8 of 10
Document Has Been Signed on 10/22/2025 08:29 PM - It Cannot Be Edited


Created By: Jacques Leffall On 10/22/2025 at 07:34 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: VILLA MIRAGE OF CARMEL
FACILITY NUMBER: 275201906

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 1 Fire Drill log which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2025
Plan of Correction
1
2
3
4
Licensee agrees to conduct a fire drill and submit a copy of the FIre Drill log to CCLD by POC due date.
Type B
Section Cited
HSC
1569.72(c)
Levels of Care
(c) Notwithstanding paragraph (2) of subdivision (a), bedridden persons may be admitted to, and remain in, residential care facilities for the elderly that secure and maintain an appropriate fire clearance. A fire clearance shall be issued to a facility in which one or more bedridden persons reside if either of the following conditions are met:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 1 fire drill which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2025
Plan of Correction
1
2
3
4
Licensee agrees to conduct a fire drill and submit a copy of the FIre Drill log to CCLD by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Jacques Leffall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2025


LIC809 (FAS) - (06/04)
Page: 9 of 10
Document Has Been Signed on 10/22/2025 08:29 PM - It Cannot Be Edited


Created By: Jacques Leffall On 10/22/2025 at 07:34 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: VILLA MIRAGE OF CARMEL
FACILITY NUMBER: 275201906

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87469(a)
Advance Directives and Requests Regarding Resuscitative Measures
(a) Upon admission, a facility shall provide each resident, and representative or responsible person of each resident, with written information about the right to make decisions concerning medical care. This information shall include, but not be limited to, the Department's approved brochure entitled “Your Right To Make Decisions About Medical Treatment,” PUB 325, (3/12) and a copy of Sections 87469(b), (c) and (d) of the regulations.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above in 1 out of 1 resident does not possess a Consent for Medical treatment in resident file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/05/2025
Plan of Correction
1
2
3
4
Licensee agrees to complete the Consent for Medical treatment form and submit to CCLD by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Jacques Leffall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2025


LIC809 (FAS) - (06/04)
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