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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005513
Report Date: 11/05/2024
Date Signed: 11/05/2024 12:55:54 PM

Document Has Been Signed on 11/05/2024 12:55 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
ORANGE COUNTY ASC, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CARMEL VILLAGE RETIREMENT COMMUNITYFACILITY NUMBER:
306005513
ADMINISTRATOR/
DIRECTOR:		JUSTINE M. ORTIZFACILITY TYPE:
740
ADDRESS:17077 SAN MATEOTELEPHONE:
(714) 962-6667
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 220TOTAL ENROLLED CHILDREN: 0CENSUS: 179DATE:
11/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:10 AM
MET WITH:Laura Foreman - Memory Care DirectorTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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On 11/5/2024, LPAs Dwayne Mason Jr. and William Vanegas arrived at the facility for the purpose of conducting a Case Management visit for the purpose of following up on incident reports received by the Department. LPAs were greeted and granted entry by Front Desk/Receptionist Silvia Villalobos. LPAs met with Laura Foreman, Memory Care Director.

LPAs obtained copies of the resident roster, staff roster, staff schedules and staff training logs. LPAs requested an electronic copy of the call button report from 10/21/2024 through 11/4/2024. LPAs conducted interviews with Memory Care Director, staff and residents. Based on staff interviews conducted, the majority of staff indicated that the facility is understaffed. However, based on interview with MCD, it was revealed that the facility utilizes a staffing agency called Pioneer Home Care to fill any call-outs from staff. MCD also showed LPA the job postings currently on the facility's website indicating the facility is currently hiring.

Based on today's visit no deficiencies are being issued. This report was reviewed with facility staff and a copy was provided.
Armando J LuceroTELEPHONE: (949) 430-1222
Dwayne L MasonTELEPHONE: () -
DATE: 11/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/05/2024
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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