306005513-3-15-2023-22-AS-AORZ-CQ82JA-20230323172559

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005513
Report Date: 03/15/2023
Date Signed: 03/15/2023 12:52:41 PM

Unsubstantiated

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
09/01/2022 and conducted by Evaluator Rosie Quiroz

COMPLAINT CONTROL NUMBER: 22-AS-20220901132618

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: 178	DATE:	03/15/2023
		UNANNOUNCED	TIME BEGAN:	12:09 PM
MET WITH:	Charles Eusey, Administrator		TIME COMPLETED:	12:23 PM

ALLEGATION(S):

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-Facility did not provide adequate supervision resulting in resident jumping out a window.

INVESTIGATION FINDINGS:

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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit to deliver findings on an investigation completed by the Department. LPA was greeted and granted entry into the facility by front desk concierge and met with Administrator Charles Eusey 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. The purpose of today’s visit is to follow up on an investigation conducted by the Department regarding the above allegation. The investigation conducted revealed the following:
On August 31, 2022 Resident 1 (R1) jumped out of a second story window of the facility memory care due to their belief that they were being chased by bad guys. Upon being found, R1 was transferred to the hospital and diagnosed with a left frontal scalp abrasion, left ankle pain, left foot pain, and right wrist pain. Prior to the incident, 5 of 8 staff interviewed reported R1 had began engaging in unusual behavior such as sitting on the ground at the facility. No falls were witnessed during these incidents.
CONTINUED...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
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.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20220901132618

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: 03/15/2023

NARRATIVE

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CONTINUED...
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.
Staff reported last checking on R1 around 11:30 AM. At approximately 12:15 PM staff reported R1 was found bloodied and wandering the downstairs patio. Per Wellness Director and Memory Care Director, facility staff are to check on residents every two hours.
A review of the physical plant confirmed locks were placed on resident windows, however, interviews reported R1 was able to bypass the window lock by lifting the window frame out of the window. Upon entering R1’s room, staff observed R1’s window screen to be off, bent up and setting next to the window.
R1 had a known history of depression and generalized anxiety with dementia; however, had no history of suicidal ideation. During an interview with R1, R1 appeared to be alert to time and space and acknowledged jumping out the window due to being in fear of their life as they believed a man and woman were going to torture them for information. R1’s spouse reported believing R1’s hallucinations are a result of medications R1 was placed on.
Hospital records obtained confirm upon assessment, hospital staff noted it was difficult to discern at the time of admittance if R1 had any suicidal ideation. R1 was assessed to be able to make their own decisions.
Following the incident, the facility has placed an extra lock at the top of all memory care windows to prevent the screens from being removed out. In addition, caregivers and maintenance staff are now expected to check on windows.
Based on the investigation, the allegation that Facility did not provide adequate supervision resulting in resident jumping out a window was 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 violation occurred.
An exit interview was conducted with Administrator Charles Eusey and Health and Wellness Director Laura Sanchez, and a copy of this report, and confidential names list were left at the facility.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
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

LIC9099 (FAS) - (06/04)

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