306005513-2-28-2025-22-AS-AORZ-DFLVC9-20250410161847

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005513
Report Date: 02/28/2025
Date Signed: 02/28/2025 11:13:26 AM

Substantiated

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 COMMUNITY		FACILITY NUMBER:	306005513
ADMINISTRATOR:	BENTON, DONALD		FACILITY TYPE:	740
ADDRESS:	17077 SAN MATEO		TELEPHONE:	(714) 962-6667
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	220	CENSUS:	DATE:	02/28/2025
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:			TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff is yelling at resident

INVESTIGATION FINDINGS:

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Findings: allegation: Staff is yelling at resident.
Licensing Program Analysts (LPAs) Samer Haddadin, and Rose Ruppert conducted an unannounced complaint visit to deliver findings on the above allegation. LPAs were greeted and granted entry into the facility 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 is yelling at resident. The investigation determined as follows:
LPA conducted interviews with three staff members and three residents. The investigation revealed three of three residents’ interviews could not support the allegation due to their cognitive ability and mental awareness. Meaning, residents did not completely understand what the LPA was asking them.
However, one of three staff interviews collaborated the allegation, while two of three staff interviews denied seeing or witnessing any staff yelling at residents.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Samer Haddadin	TELEPHONE: (714) 790-2096
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

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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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: 02/28/2025

NARRATIVE

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LPA reviewed staff records for S1 and observed that on April 3, 2023, S1 was reprimanded and put on 90-day probation for unprofessional conduct and yelling at residents. Also, staff record shows that on September 20th, S1 was given a final reprimand which led to termination of staff on October 9th, 2023. S1 is no longer employed due to past similar incidents.
Therefore, based on the preponderance of evidence through interviews, documentation allegation that staff is yelling at resident is deemed SUBSTANTIATED. A deficiency is being cited per Title 22, Division 6, Chapter 8 of the California Code of Regulations. See LIC9099D.
An exit interview was conducted, and a copy of this report was provided to facility administrator along with appeal rights.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Samer Haddadin	TELEPHONE: (714) 790-2096
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

LIC9099 (FAS) - (06/04)

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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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/28/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/28/2025 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	87468.1(a)(1) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.	1 2 3 4 5 6 7	Licensee did terminate employee as evident by paperwork provided and e mailed to LPA. POC was corrected by facility
	8 9 10 11 12 13 14	This requirement was not met as evidenced by facility employee yelled at resident which posed a protentional personal rights risk to residents in care. *THIS IS AN AMENDED DEFICIENCY PAGE.*	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Samer Haddadin	TELEPHONE: (714) 790-2096
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

LIC9099 (FAS) - (06/04)

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