306005513-6-14-2024-22-AS-AORZ-D7HKAC-20240725074339

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005513
Report Date: 06/14/2024
Date Signed: 06/14/2024 12:44:28 PM

Unsubstantiated

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
05/07/2024 and conducted by Evaluator RoseMarie Ruppert

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20240507144901

FACILITY NAME:	CARMEL VILLAGE RETIREMENT COMMUNITY		FACILITY NUMBER:	306005513
ADMINISTRATOR:	CHARLES J EUSEY III		FACILITY TYPE:	740
ADDRESS:	17077 SAN MATEO		TELEPHONE:	(714) 962-6667
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	220	CENSUS: 173	DATE:	06/14/2024
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Justine Ortiz, Administrator		TIME COMPLETED:	10:45 PM

ALLEGATION(S):

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Staff do not prevent a resident from sustaining multiple falls while in care

INVESTIGATION FINDINGS:

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LIcensing Program Manager (LPM) Alisa Ortiz, Licensing Program Analysts (LPA) Michael Tea and Rose Ruppert made an unannounced visit to the facility today to conduct a complaint follow-up visit. LPM and LPAs were greeted and granted entry by Jennifer Cerda, Concierge. During today’s visit, LPM and LPAs met with Justine Ortiz, Administrator.

LPM and LPA Ruppert reviewed resident's (R1) Service Plan, Physician's Report (LIC 602A), Progress Notes and medical file. LPA Ruppert conducted interviews with facility staff. The investigation determined the following:
It was alleged staff did not prevent a resident from sustaining multiple falls while in care due to R1 sustaining five falls within a thirty day period. R1 moved into the facility on March 1, 2024. R1 is ambulatory with the assistance of a walker, is able to communicate needs and had a secondary diagnosis of Mild Cognitive Impairment (MCI) based on the LIC 602A dated on March 8, 2024.
(Continuation...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie Ruppert	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

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-20240507144901

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: 06/14/2024

NARRATIVE

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(Continued...)
Per Needs and Service Plan dated May 6, 2024, R1 was assessed by the facility to be a high risk for falls. R1 sustained unwitnessed falls on April 2 and April 28, 2024. Facility spoke with R1's responsible party (RP) on April 28, 2024 regarding R1's change of condition. As a result facility spoke to RP about memory care placement and removed items from the apartment that could be potentially harmful. Following discussion with RP, R1 sustained falls on April 29th, 30th and May 1, 2024. Facility sought medical attention on April 30th and May 1st. RP was notified by facility of incidents after each fall. Upon return facility retained a private caregiver to provide additional supervision for R1 on May 2, 2024. Per email from Agape Home Care to facility on May 16, 2024, Agape Home Care was notified by RP on May 6, 2024 to stop service. RP advised facility that they would make arrangements for their own private caregiver for R1. On May 7, 2024 R1 sustained an unwitnessed fall. 911 was called and R1 was transported to the hospital. Health and Wellness Director notified RP of fall and the absence of a private caregiver. RP advised they were aware and was planning to provide supervision themselves and had been en route to the facility when the fall occurred. Following the fall, RP notified facility of intent to move R1 to a higher level of care. Shortly after moving on May 8, 2024 it was reported R1 passed away.

Interviews with three of three staff members confirmed they were aware of R1's fall risk and that measures had been put in place to prevent falls from occurring. Two of the three staff members stated falls could have been prevented if a private caregiver was provided. Facility progress notes show staff were monitoring R1 continuously.

Based on the preponderance of evidence, the allegation that staff do not prevent a resident from sustaining multiple falls while in care is unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations occurred.

No deficiencies cited during today's visit.

An exit interview was conducted with Administrator Justine Ortiz and a copy of this report was provided.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 287-4084
LICENSING EVALUATOR NAME: RoseMarie Ruppert	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024

LIC9099 (FAS) - (06/04)

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