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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005513
Report Date: 11/02/2023
Date Signed: 11/02/2023 11:56:36 AM


Document Has Been Signed on 11/02/2023 11:56 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 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: 170DATE:
11/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Laura SanchezTIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Ruth Martinez made visit to this facility to conduct a case management visit. LPA arrived at facility was greeted and granted entry by receptionist. LPA met with Laura Sanchez, Resident Care Coordinator and Terrie Sherrell, Regional Director of Health and Wellness and explained the nature of the visit.

LPA is conducting this visit as a follow up on an incident that was self reported an on October 24, 2023 regarding resident R1’s incident on October 20, 2023.

During today’s visit, LPA interviewed staff and obtained copies pertinent documents. LPA toured the facility and observed R1 during activities with other residents.

On October 20, 2023 at approximately 5:30pm staff received a call from R1's son notifying staff that R1 had called son from near by store. Staff immediately went to pick up resident and bring them back to the community. Upon return R1 was immediately evaluated by resident care coordinator, no injuries were noted. Primary care physician was notified and Health and Wellness Director. When R1 was interviews R1 was able to recall the whole process of the incident. Due to the nature of R1's recall the following was done out of protocol procedures: resident was assessed, 24 hour caregiver was put in place, all door codes were changed and place on a rotation for change of code, and an in-service training was conducted for all staff/all shift regarding elopement and code safety. Code safety measure are in place and continuous training is provided.

This report was reviewed with facility representatives and a copy of the report was provided and left at the facility.

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Ruth MartinezTELEPHONE: (657) 285-1397
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2023
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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