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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005513
Report Date: 04/30/2025
Date Signed: 04/30/2025 09:58:31 AM

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
03/18/2022 and conducted by Evaluator Samer Haddadin
COMPLAINT CONTROL NUMBER: 22-AS-20220318131858
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: DATE:
04/30/2025
UNANNOUNCEDTIME BEGAN:
08:22 AM
MET WITH:TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility staff mismanaged resident's medications.
Facility staff are not adequately trained.
Facility laundry room is not maintained clean
Resident's sleep is disturbed by staff slamming doors, conversations and other activitities.
Facility does not have adequate lighting.
Facility does not have adequate staff to meet the needs of the residents.
Resident was not given their test results upon request.
Facility is in disrepair.
Facility does not provide a safe environment for residents.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Samer Haddadin conducted an unannounced complaint visit to present findings regarding the allegations. Upon arrival, LPA Haddadin was greeted, granted entry to the facility, and explained the purpose of the visit.
During the investigation, LPA Haddadin toured the facility, interviewed staff members and residents, and reviewed both staff and resident files.
The following allegations were investigated: "Resident's sleep is disturbed by staff slamming doors, conversations, and other activities"; "Facility staff mismanaged resident's medications"; "Facility does not have adequate staff to meet the needs of the residents"; "Facility staff are not adequately trained"; "Facility laundry room is not maintained clean"; "Facility does not have adequate lighting"; "Resident was not given their test results upon request"; "Facility is in disrepair"; and "Facility does not provide a safe environment for residents." The findings of the investigation are as follows:
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025
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-20220318131858
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: 04/30/2025
NARRATIVE
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Regarding the allegation of "Facility staff mismanaged resident's medications," it was reported that Resident 1 (R1)'s medication was not being administered promptly or in the correct dosages. LPA Haddadin conducted six staff interviews, three of whom were Medical Technicians. These interviews did not corroborate the allegation, and all staff members denied any mishandling of residents' medications. Six resident interviews also yielded denials of the allegations. Furthermore, LPA Haddadin interviewed R1, who stated they had previously experienced issues with the timely and correct administration of medications. However, R1 reported that the facility no longer manages their medications as R1 now self-administers. Additionally, LPA Haddadin observed a Medical Technician distributing medications to four randomly selected residents. The Medical Technician utilized electronic software that logs the time and date, and the software displays the medication name, resident's name, room number, and resident's picture, all of which staff verified before administering the medication.
For the allegations: "Facility laundry room is not maintained clean," "Facility does not have adequate lighting," and "Facility is in disrepair," the investigation, through six staff interviews and six resident interviews, found no support for these claims. LPA Haddadin also conducted a walkthrough of the two laundry rooms and observed both to be clean, free of odors and debris. Both the washer and dryer were maintained and in working condition, and the trash bins were empty. Regarding the allegation of "Facility does not have adequate lighting," LPA Haddadin interviewed R1 in their room and observed an additional light stand, not present in other residents' rooms, which provided extra illumination. R1 indicated that the previous Executive Director had provided the light stand to address a lighting concern.
For the allegations: "Facility does not provide a safe environment for residents," "Resident was not given their test results upon request," and "Resident's sleep is disturbed by staff slamming doors, conversations, and other activities," LPA Haddadin conducted six staff interviews and six resident interviews, all of whom denied the allegation that the "Facility does not provide a safe environment for residents." LPA Haddadin also reviewed the facility's required Annual Inspection report, conducted on April 19, 2022, by Community Care Licensing, and found no deficiencies to support this allegation. However, regarding the allegation that "Resident was not given their test results upon request," LPA Haddadin interviewed R1, who stated that the facility did provide the test results in January but could not recall the exact date. A review of records also showed that the test results were in R1's file and accessible to the resident. For the allegation that "Resident's sleep is disturbed by staff slamming doors, conversations, and other activities," LPA Haddadin conducted six resident interviews and six staff interviews, all of whom denied the allegations.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20220318131858
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: 04/30/2025
NARRATIVE
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For the allegations: "Facility does not have adequate staff to meet the needs of the residents" and "Facility staff are not adequately trained," LPA Haddadin interviewed six residents and three staff members. Six out of six residents stated that staff respond to their calls for assistance within twelve to twenty-five minutes. All three staff members stated that they respond to residents' calls within fifteen to twenty minutes. All interviewees indicated that staff respond to residents' calls in a timely manner. Regarding the allegation that "Facility staff are not adequately trained," a review of records showed that all Medical Technicians are mandated to complete an eight-hour refresher course every six months. Furthermore, a review of staff files for the three interviewed Medical Technicians showed that they had all been employed for at least two years and had completed the required training.
Therefore, based on the preponderance of evidence gathered through interviews conducted by LPA Haddadin, the allegations: "Facility staff mismanaged resident's medications," "Facility staff are not adequately trained," "Facility laundry room is not maintained clean," "Resident's sleep is disturbed by staff slamming doors, conversations, and other activities," "Facility does not have adequate lighting," "Facility does not have adequate staff to meet the needs of the residents," "Resident was not given their test results upon request," "Facility is in disrepair," and "Facility does not provide a safe environment for residents" were found to be UNSUBSTANTIATED. This determination means that while the alleged incidents may have occurred or the concerns may be valid, there is not a preponderance of evidence to prove that the alleged violation took place.
No deficiencies were cited during today's visit. An exit interview was conducted with the Administrator, and a copy of this report was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Samer Haddadin
LICENSING EVALUATOR SIGNATURE:

DATE: 04/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3