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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005513
Report Date: 04/22/2025
Date Signed: 04/22/2025 04:03:40 PM

Document Has Been Signed on 04/22/2025 04:03 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: 173DATE:
04/22/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:00 AM
MET WITH:Mandy Taylor- Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analysts (LPAs) Jessica Cho and Edward Kim arrived at the facility unannounced for the purpose of conducting the Required 1 Year Annual Inspection. LPAs were greeted and granted entry after explaining the purpose of the visit to Executive Chef Teri McLeod. Executive Director Mandy Taylor arrived approximately 9am to assist with the annual inspection.

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 is on the first and second floor and 50% of third floor. Approved for delayed egress, and has a hospice waiver for 40 residents. There are currently 13 residents receiving hospice care services.

During the tour with ED Taylor. LPAs inspected all common areas and inspected 16 resident apartment units which had all the required elements. The residents’ personal bathrooms were checked. Toilets and water faucets worked properly, and the grab bars were secure. Showers were free of mold/mildew, and the slip resistant mats were in place. The hot water temperatures in four out of the 16 private bathrooms in the apartments exceeded 120 degrees Fahrenheit measuring at 123.0, 122.0, 126.1, and 121.2. LPAs observed one apartment unit having a strong odor from the litter box. LPAs inspected the kitchen and the dining areas. Facility maintains ample supply of two-day perishables and seven-day non-perishables. LPA observed the emergency food and water in the kitchen and supply storage. The fire extinguishers were mounted, fully charged, and serviced on July 1, 2024. The smoke/carbon monoxide detectors were last tested on November 19, 2024 per the fire alarm inspection report conducted by Tricom Fire & Electric Co. LPAs toured the outside grounds. There were ample seating and shading for the residents, and the walkways were clear of hazards.

Lourdes MontoyaTELEPHONE: (714) -70-2870
Jessica ChoTELEPHONE: 714-703-2853
DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/22/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CARMEL VILLAGE RETIREMENT COMMUNITY
FACILITY NUMBER: 306005513
VISIT DATE: 04/22/2025
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Facility conducts quarterly disaster drills with the last one conducted on January 30, 2025.

LPAs reviewed 15 residents' and 4 staff files. No discrepancies noted. Interviews were conducted with 16 residents and 4 staff. The medications and the Medication Administration Records (MARs) were reviewed. No discrepancies noted.



The following were advised: to maintain the hot water temperature between 105-120 degrees Fahrenheit and to remove the source of the odor in the apartment unit of Resident #9 (R9).

Based on the observations, a deficiency is being cited on the attached LIC9099-D, and a Technical Violation (TV) is being issued.

An exit interview was conducted with Executive Director Mandy Taylor, and a copy of this report including the LIC9099C, LIC9099-D, TV, and the appeal rights were provided at the end of the visit.
SUPERVISOR'S NAME: Lourdes MontoyaTELEPHONE: (714) -70-2870
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:

DATE: 04/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/22/2025 04:03 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
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: 04/22/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in four out of sixteen apartment units which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/23/2025
Plan of Correction
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Administrator stated that the hot water temperature will be readjusted and will provide provide the Acknowledgement of Understanding for the said deficiency to LPA via email by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Lourdes MontoyaTELEPHONE: (714) -70-2870
Jessica ChoTELEPHONE: 714-703-2853

DATE: 04/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2025

LIC809 (FAS) - (06/04)
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