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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005513
Report Date: 11/30/2021
Date Signed: 11/30/2021 12:27:46 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CARMEL VILLAGE RETIREMENT COMMUNITYFACILITY NUMBER:
306005513
ADMINISTRATOR:BENTON, DONALDFACILITY TYPE:
740
ADDRESS:17077 SAN MATEOTELEPHONE:
(714) 962-6667
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:220CENSUS: 160DATE:
11/30/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:03 PM
MET WITH:Donald "Cash" BentonAdministratorTIME COMPLETED:
12:37 PM
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Licensing Program Analyst (LPA) LPA Rosie Quiroz made an unannounced case management visit to follow up on an incident report dated 11/19/2021 received by Community Care Licensing (CCL) on 11/24/2021. LPA Quiroz met with Administrator Cash Benton and explained the reason for the visit.

Incident report dated 11/19/2021 indicated that Resident #1 was found laying on his bedroom floor. Facility called paramedics and transported resident to Huntington Beach Hospital then Placentia Hospital for Physical Therapy recommendation.

The resident is currently at St. Kathleen's Skilled Nursing Facility in Fullerton, CA receiving Physical Therapy. AD Benton indicated R1 has approximately one more week of physical therapy, and the plans are for R1 to return back to the community.

No further action required. A copy of this report was left at the facility with Administrator Cash Benton.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2021
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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