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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005513
Report Date: 08/04/2022
Date Signed: 08/04/2022 02:38:11 PM

Substantiated


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
07/27/2022 and conducted by Evaluator Rosie Quiroz
COMPLAINT CONTROL NUMBER: 22-AS-20220727164022
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: 180DATE:
08/04/2022
UNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Charles Eusey, Administrator and Nilab Popal, Business Office ManagerTIME COMPLETED:
01:59 PM
ALLEGATION(S):
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-Facility is not reporting COVID-19 Positive cases
INVESTIGATION FINDINGS:
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On today’s date, Licensing Program Analyst (LPA) Rosie Quiroz made an unannounced visit to the facility to conduct a 10 day visit to address allegation listed above. LPA Quiroz was COVID-19 screened and granted entry by front desk receptionist. LPA Quiroz met with Charles Eusey, Executive Director and Nilab Popal, Business Office Manager and discussed the purpose for today’s visit.
During the course of this investigation, LPA Quiroz conducted multiple interviews, reviewed documents including but not limited to COVID-19 share-point, COVID-19 FAS entries, Special incident reports and two fax cover letters dated 7/26/2022 at 3:58pm and 4:02pm.
Per documents reviewed and interviews conducted with interviewees; 3 of 3 Interviewees indicated “The ball was dropped and cases were not reported timely to Community Care Licensing.”
Based on the preponderance of evidence gathered through multiple interviews and documents obtained; the allegation “Facility is not reporting COVID-19 Positive cases” has been met; Therefore, the allegation listed above is deemed to be SUBSTANTIATED.
CONTINUED ON NEXT PAGE...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
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 3
Control Number 22-AS-20220727164022
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: 08/04/2022
NARRATIVE
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The facility is being cited per Title 22, Division 6 of the California Code of Regulations. (SEE LIC 9099-D)

An exit interview was conducted with (ED) Charles Eusey, and a copy of this report, along with LIC9099-D, Appeal Rights, and the LIC 811-Confidential names were provided at exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20220727164022
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/11/2022
Section Cited
CCR
87211(a)(2)
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87211(a)(2)Reporting Requirements:(a)Each licensee shall furnish to the licensing agency such reports...(2)Occurrences, such as epidemic outbreaks...shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. CONTINUED BELOW
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Executive Director and all staff assisting with reporting requirements will read CCR 87211 Reporting Requirements and submit proof of understanding CCR 87211 by POC due date of 8/11/2022.
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This requirement was not met as evidenced by:3 of 3 interviewees indicated "Dropping the ball with reporting requirements" and 2 fax cover letters dated 7/26/22 reporting 8 COVID-19 positive cases past the reporting requirement. This poses a potential risk for 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: 08/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3