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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005513
Report Date: 08/21/2024
Date Signed: 08/21/2024 03:20:20 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/16/2024 and conducted by Evaluator Ruth Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240816143222
FACILITY NAME:CARMEL VILLAGE RETIREMENT COMMUNITYFACILITY NUMBER:
306005513
ADMINISTRATOR:JUSTINE M. ORTIZFACILITY TYPE:
740
ADDRESS:17077 SAN MATEOTELEPHONE:
(714) 962-6667
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:220CENSUS: 180DATE:
08/21/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Justine Ortiz, Executive DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Facility staff did not ensure resident's food was protected against vermin.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ruth Martinez made an unannounced visit to conduct the initial visit to begin the investigation into the allegation listed above. LPA met with Justin Ortiz, Executive Director and explained the nature of the visit.

Based on the information obtained during this investigation the department has concluded the investigation into the above mentioned allegation. Findings are based upon this investigation which included interviews conducted, tour of the physical plant of the facility, resident file review, and copies of pertinent documents obtained (Pest Flex pest control contract and service invoices).

It is alleged that facility staff did not ensure resident’s food was protected against vermin. Interview conducted with resident (R1) stated that R1 had an issue with vermin in their sandwich 3 years ago. R1 stated

Continued on LIC9099-C
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 22-AS-20240816143222
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CARMEL VILLAGE RETIREMENT COMMUNITY
FACILITY NUMBER: 306005513
VISIT DATE: 08/21/2024
NARRATIVE
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that they had not had an issue since then with vermin. File review of resident records revealed that R1 admission to the facility was March 25, 2023, about a year and 4 months ago. Interview with 13 of 13 residents revealed that residents have not ever had an issue with vermin in their food or have seen any vermin in the facility. Residents stated that they were very happy with the food quality of the facility. LPA obtained statements from the staff who stated that facility has had continuous pest control service from an outside vendor, which comes twice a month to do pest control maintenance. Records review reflect that facility has a contract with Pest Flex to services the facility. Copies of records obtained reflect that facility has a service agreement for pest control indicating facility had a previous pest company prior to contracting with them. Services instructions indicate to treat exterior and interior, focusing in kitchen areas, semi-monthly services, 2x month and service existing equipment.

We have found the complaint allegation is unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

A copy of this report is being reviewed with the Executive Director and a copy furnished to the facility.
SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Ruth Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2