306005513-7-21-2023-22-AS-AORZ-CU2TAB-20230724143317

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005513
Report Date: 05/17/2023
Date Signed: 07/21/2023 01:12:18 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/29/2022 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20220929163554

FACILITY NAME:	CARMEL VILLAGE RETIREMENT COMMUNITY		FACILITY NUMBER:	306005513
ADMINISTRATOR:	BENTON, DONALD		FACILITY TYPE:	740
ADDRESS:	17077 SAN MATEO		TELEPHONE:	(714) 962-6667
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	220	CENSUS: 173	DATE:	05/17/2023
		UNANNOUNCED	TIME BEGAN:	10:18 AM
MET WITH:	Charles Eusey, Administrator and Laura Sanchez, Health and Wellness Director		TIME COMPLETED:	10:49 AM

ALLEGATION(S):

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-Facility has not eradicated insect infestation

INVESTIGATION FINDINGS:

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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz and Licensing Program Manager (LPM ) Alisa Ortiz made an unannounced visit for the purpose to deliver findings for complaint allegation listed above. LPA Quiroz and LPM Ortiz were greeted and met with Executive Director (ED) Charles Eusey and discussed purpose of today's visit.
Regarding the allegation "Facility has not eradicated insect infestation," investigation revealed the following: Documents received dated 6/22/2022, 7/27/2022 and 8/24/2022 confirmed facility has a contracted exterminator company providing pest control services. The contracted company provides routine monthly maintenance to the facility. In addition the facility Maintenance Director provides as needed room treatment when requested by residents. Invoices reviewed do not show any reports of pest activity present at the facility. Interviews conducted with three of three stafff denied ever observing pest and/or insects within the facility. CONTINUED...
***THIS IS AN AMENDED REPORT***

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20220929163554

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 COMMUNITY	FACILITY NUMBER: 306005513
	VISIT DATE: 05/17/2023

NARRATIVE

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CONTINUED...Interviews conducted with Staff revealed Resident 1 (R1) denies facility housekeeper access to their bedroom for routine cleaning and sanitation. Five of six residents interviewed denied observing bugs, insects or any other pest activity present throughout the facility or in their bedroom area. During facility inspection tour visit conducted on 10/6/2022 by LPA Quiroz and LPA Ramirez, LPAs toured 5 of 6 resident's bedroom areas. During facility inspection of 5 of 6 bedroom area, LPAs Quiroz and Ramirez did not observe any insect, bugs, or rodents throughout the facility.

Therefore based on the preponderance of evidence through interviews and observations conducted by LPA Quiroz and LPA Ramirez, the allegation that the "Facility has not eradicated insect infestation," is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. This agency has investigated this complaint.

No deficiencies cited during today's visit.

An exit interview was conducted with Charles Eusey, Administrator and Laura Sanchez, Health and Wellness Director and a copy was provided.

***THIS IS AN AMENDED REPORT***

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC9099 (FAS) - (06/04)

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