306005513-5-17-2023-22-AS-AORZ-CTHMX3-20230707095916

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005513
Report Date: 05/17/2023
Date Signed: 05/17/2023 05:35:46 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
03/15/2021 and conducted by Evaluator Rosie Quiroz

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210315130638

FACILITY NAME:	CARMEL VILLAGE RETIREMENT COMMUNITY		FACILITY NUMBER:	306005513
ADMINISTRATOR:	BENTON, DONALD		FACILITY TYPE:	740
ADDRESS:	17077 SAN MATEO		TELEPHONE:	(714) 962-6667
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	220	CENSUS: 173	DATE:	05/17/2023
		UNANNOUNCED	TIME BEGAN:	02:02 PM
MET WITH:	Charles Eusey, Administrator		TIME COMPLETED:	02:54 PM

ALLEGATION(S):

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-Personal Rights are being violated

INVESTIGATION FINDINGS:

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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz and Licensing Program Manager (LPM ) Alisa Ortiz made an unannounced visit for the purpose to deliver findings for complaint allegation listed above. LPA Quiroz and LPM Ortiz were greeted and met with Executive Director (ED) Charles Eusey and discussed purpose of today's visit.
Regarding the allegation "Personal Rights are being violated," investigation revealed the following:
It was reported that the Resident's 1 (R1) personal rights were being violated due to (R1) not receiving a refund upon moving out of the facility. (R1) was admitted to the facility on 2/26/2021 at which time they paid a $2800 fee for facility community fee. Per (R1s) admission agreement community fees are a one time payment paid to the facility to cover services such as: processing application, conducting pre appraisal and development of care plan. The community fee is not considered a security deposit. On 3/8/2021 (R1) provided a 30 Day notice of intention to vacate the facility.
CONTINUED...

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

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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Control Number 22-AS-20210315130638

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/17/2023

NARRATIVE

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CONTINUED...
Per Title 22 California Code Of Regulations Admission Agreements: 87507-(g)(5)(E)(2)(a). (R1) is entitled to a 80% refund in excess of $500 of pre admission fee if they move out of the facility within 30 day of move in.
(R1) moved out of the facility on 4/7/2021. Billing records reviewed confirmed (R1) received 80% of preadmission fee in excess of $500 on 5/28/2021. (R1) later received a second refund from the facility on 7/2/2021 for an additional $448.53. Per interview with Former Administrator Cash Benton the request for (R1s) refund was put in with facility payroll unit upon notice of (R1s) intention to move out. However, refund was delayed due to accounting delay. Although refund was delayed (R1) received required refund and additional refund from the facility.

Therefore based on the preponderance of evidence through interviews, documentation review and observations conducted by LPA Quiroz, the allegation that the "Personal Rights are being violated," is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. This agency has investigated this complaint.

No deficiencies cited during today's visit.

An exit interview was conducted with Executive Director Charles Eusey, and a copy of report was provided

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC9099 (FAS) - (06/04)

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