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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005513
Report Date: 05/17/2023
Date Signed: 05/17/2023 05:32:47 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
02/07/2022 and conducted by Evaluator Rosie Quiroz
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220207122742
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: DATE:
05/17/2023
UNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Charles Eusey, AdministratorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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-The facility is not providing the special diet to the resident as ordered by the physician.
-Resident's personal rights were violated. One of the employees of the facility ate the resident's personal ice cream in the facility freezer.
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 allegations 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 allegations "The facility is not providing the special diet to the resident as ordered by the physician" and "Resident's personal rights were violated. One of the employees of the facility ate the resident's personal ice cream in the facility freezer," the investigation revealed the following:
It was reported that Resident (R1) was allergic to all pork products. Documentation including physician reported dated 11/24/2020 confirmed (R1) as beign allergic to lard and all pork products. (R1s) Needs and services plan dated 3/22/2022 notes facility is aware of (R1s) food allergy and lists (R1) as having a therapeutic diet. The Needs and Service Plan further notes (R1) is able to determine own food choices. Interview conducted with (R1) reported facility was providing them with jello as desert.
CONTINUED...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
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)
Page: 1 of 2
Control Number 22-AS-20220207122742
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...
Interview conducted with three of three staff confirmed (R1) was served jello however alternative desert options were readily available to (R1). Interviews conducted with two of three residents confirmed facility provides desert alternative with meals. Interview conducted with (R1) disclosed that (R1) did not care for alternative options made available and purchased his own ice cream of choice. (R1s) ice cream was initially stored in facility freezer. However, (R1) later reported Staff 1 (S1) had eaten their ice cream. Interviews with staff were unclear as to whether or not (R1) had consumed all of his ice cream or if it was mistakenly consumed by another staff or resident. Although, gelatin may contain cow and/or pig by-products and (R1) was served gelatin by the facility. The staff were unaware of jell-o containing pig by-product and non-pork related alternatives were readily available to (R1).


Therefore based on the preponderance of evidence through interviews conducted, documentation review and observations conducted by LPA Quiroz, the allegation that the "The facility is not providing the special diet to the resident as ordered by the physician," and "Resident's personal rights were violated. One of the employees of the facility ate the resident's personal ice cream in the facility freezer" were found to be UNSUBSTANTIATED, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiencies cited during today's visit.

An exit interview was conducted with Administrator Charles Eusey and a copy of this report was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Rosie Quiroz
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)
Page: 2 of 2