306005513-8-3-2023-22-AS-AORZ-CV6S3F-20230829133103

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005513
Report Date: 08/03/2023
Date Signed: 08/03/2023 04:10:58 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
10/02/2020 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20201002130659

FACILITY NAME:	CARMEL VILLAGE RETIREMENT COMMUNITY		FACILITY NUMBER:	306005513
ADMINISTRATOR:	BENTON, DONALD		FACILITY TYPE:	740
ADDRESS:	17077 SAN MATEO		TELEPHONE:	(801) 815-0808
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	220	CENSUS: 177	DATE:	08/03/2023
		UNANNOUNCED	TIME BEGAN:	09:02 AM
MET WITH:	Nilab Popal, Business Office Manager, Laura Sanchez, Health Wellness Director and Terrie Sherrell, Regional Director of Health and Wellness.		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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-Facility failed to notify responsible party of medical emergency
-Resident's bedroom was left in unsanitary condition

INVESTIGATION FINDINGS:

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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz made an unannounced visit for the purpose to deliver findings for complaint allegations listed above. LPA Quiroz was greeted and met with Nilab Popal, Business Office Manager, Health Wellness Director Laura Sanchez and Terrie Sherrell, Regional Director of Health and Wellness and discussed purpose of today's visit.
Regarding the allegation, "Facility failed to notify responsible party of medical emergency," the investigation included but not limited to: Documentation review of narrative charting entries dated 01/02/2019 through 10/07/2020 and interviews conducted with interviewees consisting of staff, residents and other witnesses. Three of five interviewees indicated a voicemail message was conducted to Resident 1 (R1s) Responsible Party via voicemail message with reporting requirements of unwitnessed fall which occurred on 10/3/2020. Two of five interviewees indicated having no knowledge of reporting requirements and not knowing whether or not (R1s) responsible party was notified of incident occuring on 10/3/2020.
CONTINUED...

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: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

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-20201002130659

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: 08/03/2023

NARRATIVE

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Regarding the allegation, "Resident's bedroom was left in unsanitary condition," the investigation revealed the following: On 11/3/2020 during a virtual Tele Assistance Partnership visit conducted along with AD Cash Benton and LPA Quiroz, LPA Quiroz virtually observed (R1s) bedroom area appearing to look clean as evidence by no trash on trash basin, (R1s) bed was made and no discoloration observed on (R1s) bed linen. (R1s) bathroom area was observed to be in sanitary conditions during virtual inspection conducted on 11/3/2020. Four of seven interviewees denied allegation indicating caregivers and housekeeping staff clean bedrooms according to housekeeping schedules and as needed due to sanitary and safety concerns. Three of Seven interviewees corroborated with allegation indicating (R1) prefers to only have two preferred caregivers clean their bedroom area.

Therefore based on the preponderance of evidence through interviews conducted, documentation review and observations conducted by LPA Quiroz, the allegation that the "Facility failed to notify responsible party of medical emergency" and "Resident's bedroom was left in unsanitary condition" were found to be UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, but 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 Terrie Sherrell Regional Director of Health and Wellness and a copy of this report along with LIC 811- Confidential Names were provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 08/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/03/2023

LIC9099 (FAS) - (06/04)

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