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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005513
Report Date: 02/04/2025
Date Signed: 02/04/2025 12:17:22 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
12/02/2021 and conducted by Evaluator Samer Haddadin
COMPLAINT CONTROL NUMBER: 22-AS-20211202124852
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: 182DATE:
02/04/2025
UNANNOUNCEDTIME BEGAN:
11:52 AM
MET WITH:Kianny SotoTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Staff intimidated a resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced complaint visit to deliver findings on the above allegation. LPA was greeted and granted entry into the facility Health and Wellness Director and explained the reason for the visit.
During the investigation, LPA toured the facility, interviewed staff members and residents as well as reviewed staff files and resident files. It was alleged: Staff intimidated a resident. The investigation determined as follows:
LPA conducted interviews with three staff members and three residents. Three of three staff interviews did not support the allegation. However, one of three staff interviews did confirm observing S1 yelling at residents on multiple occasions. Per interview, S1’s yelling was not done in any way threatening or intimidating as they believed S1 was doing so due to residents being hard of hearing and not a form of intimidation.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Samer HaddadinTELEPHONE: (714) 790-2096
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 22-AS-20211202124852
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: 02/04/2025
NARRATIVE
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LPA reviewed S1 record and observed that training on subject of Personal Rights was completed by S1 on March 28, 2021. Also training for Abuse and Neglect was completed by S1 on March 1, 2021.

During residents’ interviews, LPA observed that three of three residents did not comprehend the questions asked due to their cognitive ability and mental awareness. Meaning, residents did not completely understand what the LPA was asking them.

Therefore, based on the preponderance of evidence through interviews and documentation reviewed by LPA Haddadin, the allegation that the "staff intimated resident," is UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiencies cited during today's visit. An exit interview was conducted a copy of report was provided.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Samer HaddadinTELEPHONE: (714) 790-2096
LICENSING EVALUATOR SIGNATURE:

DATE: 02/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2