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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005513
Report Date: 03/15/2023
Date Signed: 03/15/2023 12:59:27 PM


Document Has Been Signed on 03/15/2023 12:59 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 COMMUNITYFACILITY NUMBER:
306005513
ADMINISTRATOR:CHARLES J EUSEY IIIFACILITY TYPE:
740
ADDRESS:17077 SAN MATEOTELEPHONE:
(714) 962-6667
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:220CENSUS: 178DATE:
03/15/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:24 PM
MET WITH:Charles Eusey, Administrator and Laura Sanchez, Health and Wellness DirectorTIME COMPLETED:
01:00 PM
NARRATIVE
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 On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit for the purposes of conducting a case management deficiency in connection to the investigation completed under complaint control number: 22-AS-20220901132618. LPA was greeted and granted entry into the facility by Front desk concierge and met with Administrator Charles Eusey and Laura Sanchez, Health and Wellness Director, and explained the reason for the visit.

During course of the investigation, the Department interviewed staff and witnesses as well as reviewed and obtained pertinent documentation. During the investigation, 5 out of 8 staff interviewed reported Resident 1 (R1) had begun engaging in unusual behavior such as sitting on the ground at the facility. The day of the incident, staff reported attempting to place R1 in bed but reported R1 refused to stay and kept getting out and crawling around on the floor. Despite observing the change in condition, no written re-appraisal was conducted to assess R1.

The following is being cited per California Code of Regulations Title 22 Division 6.

An exit interview was conducted with Administrator Charles Eusey and Laura Sanchez, Health and Wellness Director. A copy of this report, Confidential Names list and appeal rights was provided at the time of visit.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2023
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 03/15/2023 12:59 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: 03/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/20/2023
Section Cited

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87463(c) Reappraisals. The licensee shall arrange a meeting … when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first. This requirement was not met as evidence by: 5 out of 8 staff interviewed reported R1
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(AD) Eusey and (HWD) Sanchez will read and understand CCR 87463(c), submit proof of understanding and provide training to staff on reporting resident's change of conditions to be implemented in resident's care plans and needs and services by POC due date of 3/22/2023.
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had begun engaging in unusual behavior such as sitting/crawling on the ground. No reappraisal was conducted to assess R1’s change in condition. This poses a potential risk to residents in care.
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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.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2023
LIC809 (FAS) - (06/04)
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