306005513-4-11-2024-22-AS-RQUZ-D48VXX-20240411165017

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005513
Report Date: 04/11/2024
Date Signed: 04/11/2024 04:51:09 PM

Document Has Been Signed on 04/11/2024 04:51 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	CARMEL VILLAGE RETIREMENT COMMUNITY		FACILITY NUMBER:	306005513
ADMINISTRATOR:	CHARLES J EUSEY III		FACILITY TYPE:	740
ADDRESS:	17077 SAN MATEO		TELEPHONE:	(714) 962-6667
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	220	CENSUS: 184	DATE:	04/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Laura Sanchez, Health and Wellness Director		TIME COMPLETED:	04:50 PM

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On today’s date, Licensing Program Analysts (LPA) Rosie Quiroz and Rose Ruppert conducted an unannounced visit for the purpose of conducting an annual required evaluation. LPAs were greeted upon entry to the facility by front desk concierge. LPAs met with Health and Wellness Director (HWD) Laura Sanchez and explained the purpose of the visit. Administrator (AD) Justine Ortiz arrrived shortly after.

AD Justine Ortiz has an Administrator certificate with expiration date of 11/4/2023. AD Ortiz indicated submitting payment and CEU's and pending renewal. AD Ortiz agreed to submit copy of Administrator certificate to CCLD upon receiving it.

The facility is licensed to provide services to residents age range 60 and over, (220) Non-ambulatory, of which 20 may be bedridden. Non Ambulatory on first and second floor and 50 percent of third floor. Approved for delayed egress, and has a hospice waiver for (40) forty residents. There are currently thirty four (34) residents receiving hospice care services.

Between 9:55am-11:20am, LPAs reviewed ten (10) resident files and ten (10) personnel files. Six of ten personnel files were missing health screening and Tuberculosis test screenings. (SEE LIC 809-D)

LPAs along with AD Justine Ortiz and Maintenance Director Alfonso Cerda toured the interior and exterior of facility premises. The required two (2) day perishable and seven (7) day non-perishable food supply was observed. Toxic substances were locked and inaccessible to residents. LPAs observed cooking areas to be maintained with cleanliness. LPAs observed facility refrigerator and freezer to be operational and met regulatory requirements. Resident bathrooms were observed to have working sinks, faucets and flushing toilets. LPAs tested hot water temperatures in seven (7) resident bathrooms which ranged between 113.0 degrees- 120.2 degrees Fahrenheit. Grab bars and non-skid mats were also observed in resident bathrooms. Personal hygiene items for resident use were observed in each bathroom. LPAs observed all resident rooms to have required linens, furnishings, and adequate lighting. (CONTINUED ON LIC 809 C)

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

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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Document Has Been Signed on 04/11/2024 04:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 04/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87412(a)(11)

Personnel Records 87412(a)(11): The licensee shall ensure that personel records are maintained on the Licensee, Administrator and each employee. Each personnel record shall contain the following information; (11) a health screening as specified in Section 87411, personnel requirements-general. This requirement is not met as evidenced by: Six of ten personnel files reviewed on today's date did not have health screening and tuberculosis test screening.
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/18/2024
	Plan of Correction
1 2 3 4	AD Justine Ortiz agreed to have health screenings and TB tests for six identified employees by 4/18/2024 COB.

Type B

Section Cited

CCR

87705(f)(1)

Care of Persons with dementia(f)(1): (f) The following shall be stored inaccessible to residents with dementia. (1)Knives, matches, firearms, tools and other items that could constitute a danger to the residents. This requirement is not met as evidenced by: During inspection tour of resident's bedroom, LPAs observed knife near kitchen sink. Resident DX with MCI and history of sundowning behavior.
	Deficient Practice Statement
1 2 3 4	Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/15/2024
	Plan of Correction
1 2 3 4	AD Ortiz and Maintenance Director removed knife, hammer and scissors during time of inspection visit, agreed to reassess resident's physician report.

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: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CARMEL VILLAGE RETIREMENT COMMUNITY	FACILITY NUMBER: 306005513
	VISIT DATE: 04/11/2024

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CONTINUED...All linens and furnishings were clean and in good repair. Smoke alarms and carbon monoxide detectors were last serviced on 2/15/2023 by Tricom Fire and Electric Company. The medications were inaccessible to residents, centrally stored and maintained in compliance. All pathways, doorways, and emergency exits were observed to be free of obstruction. There were no bodies of water observed anywhere on the property. Emergency lights for use in the event of a power outage are stored in medication room area. PPE stored in Building #2, second floor area.

LPAs observed staff answer facility telephone which verified a working telephone was maintained at the facility. Regulatory required postings were observed in the resident mail box area of the facility. Facility was operating within the allowed capacity. Fire extinguishers were charged, mounted throughout the facility and last serviced 7/11/2023. Facility indicated Pest Control services facility two times per month, last serviced on 3/29/2024. LPAs verified that fire/disaster drills are conducted at least quarterly and on each shift. Last fire drill was conducted on 2/8/2024. The Emergency exit plans were posted and available for reference throughout the facility. Residents were accorded clean and comfortable accommodations.

Based on the observations made during today’s visit, the facility cited per Title 22, Division 6, of the California Code or Regulations. An exit interview was conducted with ED Justine Ortiz. A copy of today's report, LIC 809-D, Appeal rights and LIC 858 and LIC 859 pages were provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC809 (FAS) - (06/04)

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