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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005513
Report Date: 07/21/2023
Date Signed: 07/21/2023 01:14:38 PM


Document Has Been Signed on 07/21/2023 01:14 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:CHARLES J EUSEY IIIFACILITY TYPE:
740
ADDRESS:17077 SAN MATEOTELEPHONE:
(714) 962-6667
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:220CENSUS: 178DATE:
07/21/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Charles Eusey, Administrator and Laura Sanchez, Health and Wellness DirectorTIME COMPLETED:
01:13 PM
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LPA Quiroz was greeted by Front desk concierge and met with Administrator (AD) Charles Eusey and Health Wellness Director (HWD) Laura Sanchez, and explained the purpose of the inspection visit.
This unannounced Case Management – Other inspection visit is being conducted by Licensing Program Analyst (LPA) Rosie Quiroz for the purpose of delivering amended findings for Complaint Control Numbers: 22-AS-20221011152147 and 22-AS-20220929163554 based on report corrections and complaint follow up investigation requiring interviews, review of supporting documents and facility observations for the following complaint control numbers: 22-AS-20201002130659 and 22-AS-20210324151302.

During today's inspection, LPA Quiroz along with AD Eusey toured the memory care unit area consisting of resident's bedrooms, hallways and dining-room area. LPA Quiroz and AD Eusey discussed the previously delivered findings and the amended findings and LPA Quiroz delivered the amended reports.

An exit interview was conducted and copy of this report and the amended reports were discussed with and provided to AD Eusey.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/21/2023
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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