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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005513
Report Date: 11/18/2025
Date Signed: 11/18/2025 02:17:14 PM

Unfounded


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
11/23/2021 and conducted by Evaluator Michael Tea
COMPLAINT CONTROL NUMBER: 22-AS-20211123115313
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: 194DATE:
11/18/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Mandy TaylorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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- Resident sustained an unexplained injury while in care
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to conclude and deliver findings for a complaint investigation. LPA Tea was greeted and granted entry by facility staff and explained the reason for the visit. Executive Director (ED) Mandy Taylor arrived later to assist with the visit.

On November 23, 2021, the Department received a complaint alleging that a resident sustained an unexplained injury while in care. During the investigation, LPA Tea conducted interviews with facility staff and residents and reviewed relevant facility records and documentation.

The investigation revealed the following: A review of facility records showed no unusual incident reports indicating that any memory care resident sustained an unexplained injury during the period in which the complaint was received. LPA Tea interviewed three long-term memory care residents who were present at

(Complaint Investigation continued on LIC9099C)
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
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-20211123115313
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: 11/18/2025
NARRATIVE
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the facility at the time of the alleged incident. All three residents stated they did not recall any residents sustaining an injury or experiencing a fall during that time.

LPA Tea also interviewed two memory care staff members who were working during the period in question. Both staff members reported no knowledge or recollection of any resident sustaining an unexplained injury. Staff acknowledged that while falls are common among the residents’ population, they did not recall any specific incident matching the allegation.

A previous LPA assigned to the complaint interviewed a former hospice staff member who provided care at the facility during the time of the alleged incident. The hospice staff reported they did not witness any injuries, falls, or inappropriate staff conduct. They stated they had never observed staff being rough or unkind to residents and described the allegation as a “he-said, she-said” situation without substantiating evidence.

Based on LPA Tea’s observations, interviews conducted, and records reviewed, the allegation is determined to be UNFOUNDED. An unfounded finding indicates the allegation is false, could not have happened, and/or lacks a reasonable factual basis.

No deficiencies cited at this time and an exit interview was conducted with the facility. A copy of the report was provided to the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2