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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 275294324
Report Date: 10/19/2022
Date Signed: 10/19/2022 02:57:26 PM

Document Has Been Signed on 10/19/2022 02:57 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:FLANDERS COURT OF CARMEL, LLCFACILITY NUMBER:
275294324
ADMINISTRATOR:HAGERTY, MICHAELFACILITY TYPE:
740
ADDRESS:25661 MORSE DRIVETELEPHONE:
(831) 626-0824
CITY:CARMELSTATE: CAZIP CODE:
93923
CAPACITY: 6CENSUS: 8DATE:
10/19/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Michael HagertyTIME COMPLETED:
03:30 PM
NARRATIVE
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On 10/19/22, Licensing Program Analysts (LPAs) M. Medina and S. Hurt conducted a Case Management Health and Safety visit to follow up on based on observations made during an unrelated Complaint Investigation conducted on 8/31/22.

LPAs observed facility continues to be over licensed capacity and observed the facility to be storing unused wheel chairs, walkers, chairs, space heaters in the bathrooms showers and areas of the patio outside of exits.

LPA Medina received a updated copy of LIC 9020 during visit.

Deficiencies cited on the attached 809-D.

Exit interview conducted. Appeal rights provided and a copy of this report was provided for facility records.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Melinda Medina
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2022
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
Document Has Been Signed on 10/19/2022 02:57 PM - It Cannot Be Edited


Created By: Melinda Medina On 10/19/2022 at 02:15 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: FLANDERS COURT OF CARMEL, LLC
FACILITY NUMBER: 275294324

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/20/2022
Section Cited
CCR
87204(a)

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Limitations - Capacity and Ambulatory Status (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may
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Licensee to submit written plan by POC due date to bring facility into compliance. Licensee/Administrator to continue to work with APS to find suitable housing to meet resident needs. Licensee/Administrator to
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receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.
**This was not met as evidenced by LPA observed 8 residents currently in facility of which a2re identified as Independent Living.
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contact Department no later than 11/21/22 with updates and relocation information for residents.
Type B
11/04/2022
Section Cited
CCR87303(a)

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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees
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Licensee to ensure that all excess unused wheelchairs, walkers, chairs, space heaters be properly stored and not in areas intended for use of residents.
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and visitors.
**This was not met as evidenced observation of facility storing unused wheel chairs, walkers, chairs, space heaters in the bathrooms showers and areas of the patio outside of exits.
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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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Melinda Medina
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2022


LIC809 (FAS) - (06/04)
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