306005513-4-21-2025-22-AS-AORZ-DG8Q8W-20250430115727

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005513
Report Date: 04/21/2025
Date Signed: 04/21/2025 02:41:06 PM

Substantiated

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 COMMUNITY		FACILITY NUMBER:	306005513
ADMINISTRATOR:	BENTON, DONALD		FACILITY TYPE:	740
ADDRESS:	17077 SAN MATEO		TELEPHONE:	(714) 962-6667
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	220	CENSUS: 167	DATE:	04/21/2025
		UNANNOUNCED	TIME BEGAN:	01:46 PM
MET WITH:	Pam Munday, Regional VP of Operations		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff mismanaged resident's medication

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 allegation.

LPA Rosie Quiroz made an initial visit on May 28, 2022 and spoke with the Health Services Director (HSD) regarding if staff mismanaged resident's medication. The HSD stated to LPA Quiroz that the resident received the same exact dosage of medication but was taken out of another medication box.
(Continued on LIC 9099-C)

Substantiated

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 3

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)

LPA reviewed records and it is noted that the medication was not taken from the resident's medication supply but it was the same dosage. LPA spoke to the resident's family member who stated she was contacted by the facility and that the resident was accidentally given someone else's medication. When family member inquired if resident was given the wrong dose, the response was that the medication given was the exact dose.

Based on LPA record review and interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. A deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted with Pam Munday, Regional Vice President of Operations, who did not wish to sign the reports, and a copy of this report was given to the facility along with a copy of the LIC 9099-D and Appeal Rights.

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)

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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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/21/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/05/2025 Section Cited CCR 87465(h)(5)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care. (h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.	1 2 3 4 5 6 7	Facility to provide a staff in-service on medication administration and documentation. The date, desciription of the topic covered and participant signatures are to be documented and emailed to the LPA by May 5, 2025.
	8 9 10 11 12 13 14	This requirement has not been met as evidenced by: Based on LPA file review and interview, this was not followed in one of one residents, which poses a potential health and safety risk for residents in care.	8 9 10 11 12 13 14
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2025

LIC9099 (FAS) - (06/04)

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