<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005513
Report Date: 03/05/2025
Date Signed: 03/05/2025 03:51:24 PM

Document Has Been Signed on 03/05/2025 03:51 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 RO, 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: 180DATE:
03/05/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Justine Ortiz- Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jessica Cho arrived unannounced to follow-up on the death report and incident report. LPA met with Executive Director (ED) Justine Ortiz and explained the purpose of the visit.

During the course of the visit, LPA interviewed two staff and reviewed pertinent documentation such as the Death & Incident Reports dated February 19, 2025 and Progress Notes dated February 19 - February 27, 2025.

The incident is as follows: On February 25, 2025 at 3:11pm, the Department received the Incident Report (LIC624) and Death Report (LIC624A) for Resident #1 (R1). It was reported that R1 was discovered unresponsive in their room with food in their mouth by staff on February 25, 2025 at 9:37am. Per review of the Physician's Report dated January 1, 2025, R1 does have a special diet but is able to feed self. Staff performed CPR while on the 911 call. Fountain Valley Police Department and paramedics arrived to assist and transported resident to the hospital for further evaluation after detecting a pulse. R1 passed away at the hospital.

There were no health and safety violations noted during today's visit.

An exit interview was conducted with Executive Director Justine Ortiz, and a copy of this report was emailed during the visit.

Lourdes MontoyaTELEPHONE: (714) -70-2870
Jessica ChoTELEPHONE: 714-703-2853
DATE: 03/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1