306005513-12-11-2024-22-AS-AORZ-DC4LRG-20241219075904

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005513
Report Date: 12/11/2024
Date Signed: 12/11/2024 12:52:44 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY ASC, 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
12/04/2024 and conducted by Evaluator Dwayne L Mason

COMPLAINT CONTROL NUMBER: 22-AS-20241204091230

FACILITY NAME:	CARMEL VILLAGE RETIREMENT COMMUNITY		FACILITY NUMBER:	306005513
ADMINISTRATOR:	JUSTINE M. ORTIZ		FACILITY TYPE:	740
ADDRESS:	17077 SAN MATEO		TELEPHONE:	(714) 962-6667
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	220	CENSUS: 188	DATE:	12/11/2024
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Justine Ortiz - Executive Director		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Facility is malodorous

INVESTIGATION FINDINGS:

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This unannounced investigation inspection by Licensing Program Analyst (LPA) Dwayne Mason Jr. is being conducted to initiate and conclude this agency’s investigation in the complaint allegation(s) mentioned bove. LPA met with Executive Director Justine Ortiz and explained the nature of the inspection.The department received a complaint on 12/4/2024 alleging the facility is malodorous.

On 12/4/2024 LPA conducted a visit to the facility. LPA obtained copies of the resident roster and staff roster. LPA toured the facility and did not observe any malodorous smells. LPA conducted interviews with 7 residents. 6 out of 7 residents stated the hallways do not smell like urine or have a malodorous smell.
Based on observations and interviews conducted there is insufficient evidence to support the allegation(s). Although the allegation(s) may have happened or is valid; there is not a preponderance of evidence to prove that the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.An exit interview was conducted, and this report was reviewed with facility staff. A copy of this LIC-9099 was provided to the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Armando J Lucero	TELEPHONE: (949) 430-1222
LICENSING EVALUATOR NAME: Dwayne L Mason	TELEPHONE: () -
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024

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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