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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 05:34:14 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
09/22/2022 and conducted by Evaluator Rosie Quiroz
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20220922134807
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: 173DATE:
05/17/2023
UNANNOUNCEDTIME BEGAN:
11:27 AM
MET WITH:Charles Eusey, Administrator and Laura Sanchez, Health and Wellness DirectorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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-Facility failed to keep indoor passageway free of obstruction which resulted in residents fall.
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 "Facility failed to keep indoor passageway freee of obstruction which resulted in residents fall," the investigation revealed the following:
It was reported Resident 1(R1) sustained a fall at the facility on 9/10/2022 due to slipping on a piece of paper in their room. Per physician report reviewed dated 11/24/2020 (R1) is ambulatory and independent in transfers and all activities of daily living. (R1) is bling in their right and has low vision in their left eye. The facility needs and services plan dated 3/22/2022 list (R1) as being blind in both eyes and requiring escorting to meals and activities. However (R1) was not assessed to be a fall risk. Interviews conducted with two of two staff report (R1) had been denying housekeeping services and refusing housekeeping services entry to their bedroom. 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-20220922134807
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...

During LPA Quiroz's initial inspection visit conducted on 9/27/2022, LPA Quiroz observed no blockages or clutter in (R1s) bedroom. Hospital Discharge paperwork dated 9/10/2022 for (R1) after sustaining fall, reports (R1) sustained no fractures or abnormalities as a result of fall. Interview conducted with one of two residents reported that at times facility staff store items such as wheelchairs, mattresses and other items in facility stairwell. Administrator Eusey is aware of staff utilizing staff as storage and has addressed the issue with staff from reoccurring again. Although facility was utilizing stairwell as storage (R1s) fall on 9/10/2022 was unrelated to stairwell clutter.

Therefore based on the preponderance of evidence through interviews conducted, documentation review and observations conducted by LPA Quiroz, the allegation that the "Facility failed to keep indoor passageway free of obstruction which resulted in residents fall" was found to be UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiencies cited during today's visit.

An exit interview was conducted with Administrator Charles Eusey and Health and Wellness Director Laura Sanchez 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