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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005513
Report Date: 03/02/2022
Date Signed: 03/02/2022 02:20:16 PM


Document Has Been Signed on 03/02/2022 02:20 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, 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: DATE:
03/02/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Cash Benton, AdministratorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to conduct a case management and health and safety check in this facility. LPA met with Administrator (AD) Cash Benton and stated the purpose of the visit.

LPA toured both wings of the facility as well as a standard empty bedroom. Residents were observed ambulating in hallways or relaxing in the common areas.

LPA requested a copy of resident R1 physician report and admission agreement.

During this visit, LPA did not observe any immediate threat to the health and safety of residents in care. No citation has been issued at this time.

LPA Saborit-Guasch conducted an exit interview with AD Benton and a copy of this report was left in the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: Kevin Saborit-GuaschTELEPHONE: 714-703-2851
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2022
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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