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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005513
Report Date: 04/21/2025
Date Signed: 04/21/2025 01:42:59 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
04/20/2022 and conducted by Evaluator RoseMarie Ruppert
COMPLAINT CONTROL NUMBER: 22-AS-20220420165307
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: 167DATE:
04/21/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Mandy Taylor, LVN Executive Director (ED)TIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff neglect resulting in resident sustaining a pressure ulcer
Staff do not respond to resident's call for assistance in a timely manner
Staff dropped resident while assisting resident in the shower
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rose Ruppert made an unannounced visit to deliver findings for a complaint received in our office on April 20, 2022. LPA was greeted and granted entry at 12:30pm and met with Mandy Taylor, LVN, Executive Director and explained the purpose of the visit.

On February 28, 2025 LPA Ruppert obtained the resident file and reviewed: Identification Form, Physician's Report, Appraisal Needs and Services Plan and Medication list; as well as Unusual Incident Reports. LPA Samer Haddadin conducted six of six resident interviews and three of three staff interviews regarding the above allegations on February 28, 2025.

Staff and residents interviewed by LPA Haddadin were asked If they knew of staff neglect that resulted in a resident sustaining a pressure ulcer. Six of six residents and three of three staff denied this allegation.

(Continued on LIC 9099-C)

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2025
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-20220420165307
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: 04/21/2025
NARRATIVE
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(Continued from LIC 9099)

Staff and residents interviewed by LPA Haddadin were asked if staff respond to residents calls for assistance in a timely manner. Six of six residents stated calls are answered between twelve and twenty five minutes. Three of three staff stated calls are answered within fifteen to twenty minutes. All interviewed stated staff respond to residents calls in a timely manner.

Staff and residents interviewed by LPA Haddadin were asked if staff dropped a resident while assisting resident in the shower. All of the staff and residents interviewed were unaware of this and denied this allegation.

Based on LPA Ruppert's record review and LPA Haddadin's interviews with residents and staff; although the allegations above may have happened or were valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted with Executive Director Mandy Taylor, LVN, and a copy of this report was provided to the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: RoseMarie Ruppert
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2