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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005513
Report Date: 04/19/2022
Date Signed: 04/19/2022 01:55:55 PM


Document Has Been Signed on 04/19/2022 01:55 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 COMMUNITYFACILITY NUMBER:
306005513
ADMINISTRATOR:BENTON, DONALDFACILITY TYPE:
740
ADDRESS:17077 SAN MATEOTELEPHONE:
(714) 962-6667
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:220CENSUS: 167DATE:
04/19/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Excecutive Director - Chuck EuseyTIME COMPLETED:
01:10 PM
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Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced visit for the purpose of conducting an annual visit. LPA was greeted and granted entry into the facility and explained the reason for the visit.

At 11:37am, LPA toured the facility with Executive Director Chuck Eusey, Maintenance Alfonso Cerda and Health Services Director Karen Ashley . Facility has 167 residents in care during today's visit . Facility consists of Independent Living, Assisted Living with Memory Care. LPA observed a library, fitness room, salon, and activity room. LPA observed residents relaxing in the facility or participating in activities. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All resident rooms had the required elements as well as restrooms stocked with soap/ sanitizer. Rooms are single occupancy and double occupancy for married couples. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the facility. Facility utilizes a hand written visitor sign in sheet. Facility takes resident and staff temperatures daily and documents. LPA observed the first aid kit has all required items. Facility mitigation plan has been approved. Facility has emergency evacuation chairs at the top of stairwells. LPA observed an ample supply of emergency food and water. LPA observed multiple outside visitation areas. LPA observed the medication room and facility uses electronic medical records for medication management. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed select resident files during the visit and all files are up to date including emergency information. Most residents and all staff are vaccinated for Covid-19.

LPA consulted with Executive Director on the importance of posting the "Let Us No" in the entrance of facility in regulation size, 20"X26"
No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 04/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/19/2022
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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