306005513-7-21-2023-22-AS-AORZ-CU2TG3-20230724144228

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005513
Report Date: 05/17/2023
Date Signed: 07/21/2023 01:11:12 PM

Unsubstantiated

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
10/11/2022 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221011152147

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:	12:02 PM
MET WITH:	Charles Eusey, Administrator and Laura Sanchez, Health and Wellness Director		TIME COMPLETED:	12:40 PM

ALLEGATION(S):

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-Staff are unable to meet the resident's needs while in care.

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 "Staff are unable to meet the resident's needs while in care," the investigation revealed the following:
It was reported that staff are unable to meet resident's needs while in care due to Resident 1 (R1) being blind. Per physician report dated 11/24/2020 (R1) is listed as being ambulatory and able to transfer independently despite being blind in the right eye and having low vision in the left eye. Facility needs and services plan for (R1) dated 3/22/2022 list (R1) being blind in both eyes and requiring excorting to and from meals and activities. Interviews conducted with four of four staff confirmed facility staff are aware of evacuation procedures for physically and mentally impaired residents. CONTINUED...
***THIS IS AN AMENDED REPORT***

Unsubstantiated

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-20221011152147

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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Staff records reviewed confirmed staff have required emergency disaster training. Staff reported residents are checked routinely throughout the day at the start and end of all shift and during all meals. Interview conducted with (R1) reported (R1) had concerns about staff's ability to assist the residents during an emergency situation as (R1) resided on the second floor of the facility. Documentation reviewed revealed that (R1) was offered to be moved to the first floor of the facility at no additional charge on 10/7/2022. However (R1) declined offered due personal preferences.(R1) voluntarily moved out of that facility two days later.

Therefore based on the preponderance of evidence through interviews conducted, documentation review and observations conducted by LPA Quiroz, the allegation that the "Staff are unable to meet the resident's needs while in care, " was found to be UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiencies cited during today's visit.

An exit interview was conducted with Administrator Charles Eusey and Laura Sanchez, Health and Wellness Director and a copy of this report 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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