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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275202480
Report Date: 05/27/2022
Date Signed: 05/31/2022 03:45:36 PM

Document Has Been Signed on 05/31/2022 03:45 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
CCLD Regional Office,
, CA
FACILITY NAME:CARMELO PARKFACILITY NUMBER:
275202480
ADMINISTRATOR:MAZERIK, MATTHEWFACILITY TYPE:
740
ADDRESS:966 CARMELO STREETTELEPHONE:
(831) 375-0665
CITY:MONTEREYSTATE: CAZIP CODE:
93940
CAPACITY: 40; 40CENSUS: 28DATE:
05/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:J. Pinkard (Staff)TIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Albert Johnson arrived unannounced to conduct an annual inspection. LPA met with Staff and explained the purpose of the visit. Later joined by Administrator Jennifer Wigon.

LPA inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 123.5 degrees Fahrenheit in resident bathroom sink, which is not within the required range of 105 to 120 degrees.

Fire extinguishers and smoke detectors are current and in compliance with fire safety. However the Ansul system and the Riser's Five year inspection is expired and both systems needs to be serviced. This is a zero tolerance fire clearance violation. LPA observed centrally stored medications for each resident. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed 15 resident and 4 staff files, including criminal record clearances. During the resident files review LPA observed 3 outdated (LIC 602) Physician's Reports Fire drill was completed on 5/10/2022.

All staff are fingerprint cleared and associated to the facility. First aid kit was checked and is complete. Exit interview conducted appeal rights given.
SUPERVISORS NAME: Stephenie Doub
LICENSING EVALUATOR NAME: Albert Johnson
LICENSING EVALUATOR SIGNATURE: DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/27/2022
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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Document Has Been Signed on 05/31/2022 03:45 PM - It Cannot Be Edited


Created By: Albert Johnson On 05/27/2022 at 03:25 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
,
, CA

FACILITY NAME: CARMELO PARK
FACILITY NUMBER: 275202480

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/28/2022
Section Cited
CCR
87203

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87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met based on: Observation, The facility failed to maintained in conformity with the regulations
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Administrator will ensure that the fire equipment listed is inspected or a plan is made and sent to CCL by the POC date indicated. Licensee/Administrator shall send picture of the
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adopted by the State Fire Marshal. The "Fixed System" in the kitchen. This system is scheduled for a semi-annual maintenance and LPA observed that the last service was on 6/29/21 and the Riser Service is outdated for both the five year and the annual, last annual was 2018 and the last five year service was 2015. This is a zero tolerance violation.
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 new tags as proof and submit Statement of Compliance by POC date**Fire Clearance Civil Penalty Assessed***
Type A
05/28/2022
Section Cited
CCR80088(e)(1)

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Furniture, Fixtures, Equipment, and Supplies
1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C)....
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Test hot water in the bathroom to meet Title 22 regulations. Send 3 days hot water temperature to LPA via email.
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LPA measured / tested hot water at 123.5 degrees F. Licensee failed to assure hot water meeting Title 22 regulation of 105-120 degree F. This poses a health and safety risk to resident in care.
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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.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 05/31/2022 03:45 PM - It Cannot Be Edited


Created By: Albert Johnson On 05/27/2022 at 03:45 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
,
, CA

FACILITY NAME: CARMELO PARK
FACILITY NUMBER: 275202480

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/03/2022
Section Cited
CCR
87705(c)(5)

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(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment...
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The licensee shall have R1, R2 and R3 obtain an updated medical assessment/physician's report. The licensee shall submit a copy of updated physician's report to LPA via email by 6-03-22.
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Based on record review and interview, R1,R2 and R3 does not have an updated medical assessment/physician's report.
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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.
SUPERVISOR'S NAME:Stephenie Doub
LICENSING EVALUATOR NAME:Albert Johnson
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022


LIC809 (FAS) - (06/04)
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