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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005513
Report Date: 05/16/2025
Date Signed: 05/16/2025 11:49:11 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
09/20/2024 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 22-AS-20240920115247
FACILITY NAME:CARMEL VILLAGE RETIREMENT COMMUNITYFACILITY NUMBER:
306005513
ADMINISTRATOR:JUSTINE M. ORTIZFACILITY TYPE:
740
ADDRESS:17077 SAN MATEOTELEPHONE:
(714) 962-6667
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:220CENSUS: 188DATE:
05/16/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:KIANNY SOTOTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Resident sustained unexplained fracture while in care.
Resident sustained multiple falls due to lack of supervision.
INVESTIGATION FINDINGS:
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On 05/16/25, Donna Gurriere, Licensing Program Analyst (LPA) contacted the licensee via telephone to deliver final findings regarding a complaint that was received on 09/20/2024. LPA Gurriere spoke with Kianny Soto, Health and Wellness Director and explained the purpose of the call.

Resident sustained unexplained fracture while in care.

During the interview process, the Resident Care Coordinator, the resident (Resident 1), and several staff persons were interviewed. In addition, documents were reviewed and obtained to include Personnel Report, Physicians Report, Emergency Information, Admission Agreement, Appraisal and Needs, Medication Administrative Record (MARs), Incident Reports and Medical Records.


continued
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025
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-20240920115247
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: 05/16/2025
NARRATIVE
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During the investigation of a complaint received on 09/20/24, it was reported that the resident (Resident 1) pressed their pendant for assistance and when staff arrived the resident was observed on the floor lying on her back. It was stated that the resident independently tried to get out of her wheelchair and fell to the floor. The resident complained of back and hip pain and was sent by emergency services to the hospital. It was reported that the resident suffered a Lumbar Compression Fracture; however, it was not due to a lack of care and supervision.

Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated.

Resident sustained multiple falls due to lack of supervision.

During the interview process, the Resident Care Coordinator, the resident (Resident 1), and several staff persons were interviewed. In addition, documents were reviewed and obtained to include Personnel Report, Physicians Report, Emergency Information, Admission Agreement, Appraisal and Needs, Medication Administrative Record (MARs), Incident Reports and Medical Records.

During the investigation of a complaint received on 09/20/24, it was reported that the resident (Resident 1) would independently page for assistance at times; however, other times, they would try and stand on their own and then fall. Documents reviewed, indicated that staff were available to assist the resident when they needed assistance or paged them. Falls were not due to a lack of supervision.

Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated.

Licensee/health and wellness director was advised a copy of this report will be sent via certified mail. Two copies of the report will be sent. The licensee/health and wellness director is to sign and return a copy to the Orange County Regional Office.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Donna Gurriere
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2