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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005513
Report Date: 05/23/2026
Date Signed: 05/23/2026 04:28:06 PM

Unsubstantiated


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
11/28/2022 and conducted by Evaluator Arielle Pascua
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221128152508
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: 187DATE:
05/23/2026
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Mandy TaylorTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Failure to meet the resident's needs.
Failure to provide supervision resulting in inappropriate behaviors.
Residents are wandering into other residents' rooms.
Failure to follow COVID-19 protocols.
Staff ignores resident's request for help.
Facility is billing for an additional month.
Facility staff is insufficient to meet the resident's needs.
INVESTIGATION FINDINGS:
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On 05/23/2026, Licensing Program Analyst (LPA) Arielle Pascua conducted a complaint visit via telephone call regarding the complaint allegations above. Current census was 187. A brief interview with FDA Taylor was conducted.
It was alleged that the facility failed to meet the residents needs, provide supervision resulting in inappropriate behaviors, residents wander into other resident's rooms, fail to follow COVID protocols, facility staff ignore resident's request for help, facility is billing for an additional month, and is unsufficient to meet the resident's needs. LPA Pascua attempted to contact former staff from this facility to obtain additional information, however, LPA Pascua was unable to reach staff as they were no longer employed by this facility. In addition, contact with current staff deny or have not been employed by the facility during the time of the complaint. A review of the facility records were also conducted. Based on interviews conducted and observation, the allegations are found to be UNSUBSTANTIATED, meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was provided via email for signature.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Emerita Curiel
LICENSING EVALUATOR NAME: Arielle Pascua
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2026
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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