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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005513
Report Date: 06/14/2024
Date Signed: 06/14/2024 12:48:30 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
03/11/2024 and conducted by Evaluator Michael Tea
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20240311095131
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:
06/14/2024
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Justine OrtizTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Staff are not properly addressing pest infestation in facility
INVESTIGATION FINDINGS:
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An unannounced complaint investatigation was conducted on this day by Licensing Program Analysts (LPAs) Michael Tea and Rose Ruppert and Licensing Program Manager (LPM) Alisa Ortiz regarding the allegation mentioned above. LPAs and LPM met with Executive Director (ED) Justine Ortiz.

It was alleged that staff are not properly addressing pest infestation in facility. During the investigation LPAs interviewed residents and staff, checked resident files and reviewed facility maintanence invoices. The investigation determine the following:

In October 2023 Resident 1 (R1) had reported to facility about flea and mite infestation in their bedroom. Facility provided pest fumagation to R1's room. Per interview with maintanence director the facility has a contracted pest control company and contacted them to inspect for pests in R1's room. Per pest control records obtained no flea or mite activity was noted in the invoices and reports. (continued ... )

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024
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-20240311095131
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CARMEL VILLAGE RETIREMENT COMMUNITY
FACILITY NUMBER: 306005513
VISIT DATE: 06/14/2024
NARRATIVE
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(... continued) Interviews with three of three residents confirm that they have never encountered pest within the facility. Two of three residents reported they had heard of R1 reported infestation but had never observed any pest themselves. Interviews with two of two med-techs reported that R1 complained about pest bites however med-techs denied observing bites on R1. R1 was assessed by their physician and prescribed cream to assist with itching. Prescription forms provided by physician do not list any diagnoses or report of pest bites. Interviews with staff and residents indicated R1 had a dog, however the dog normally appeared well groomed and maintained and did not itch or scratch. LPA toured the room and observed no evidence of fleas or mites.

Therefore based on LPA Tea's observation and interviews conducted and records review the allegation the staff are not properly addressing pest infestation has been determined to be unsubstantiated meaning that although the allegation may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

No deficiencies cited and an exit interview was conducted with Executive Director Justine Ortiz and a copy of the report was provided to the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2