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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005513
Report Date: 05/17/2023
Date Signed: 05/17/2023 05:37:09 PM

Document Has Been Signed on 05/17/2023 05:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 COMMUNITYFACILITY NUMBER:
306005513
ADMINISTRATOR:CHARLES J EUSEY IIIFACILITY TYPE:
740
ADDRESS:17077 SAN MATEOTELEPHONE:
(714) 962-6667
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY: 220CENSUS: 173DATE:
05/17/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:13 PM
MET WITH:Charles Eusey, AdministratorTIME COMPLETED:
05:37 PM
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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an unannounced visit for the purposes of conducting a case management deficiency in connection to the investigation completed under complaint control number: 22-AS-20220207122742. LPA Quiroz was greeted and granted entry into the facility and met with Administrator Charles Eusey and explained the reason for the visit.
During course of the investigation, the Department requested documentation of dieticians last nutrition report. Administrator Eusey was not available to provide Dietician report and indicated they would be looking into it.

A Technical Violation LIC 9102 was issued during today's visit for General Food Services Requirement: 87555(b)(17)


An exit interview was conducted with Administrator Charles Eusey, and a copy of this report and LIC 9102 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
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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