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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005513
Report Date: 11/18/2025
Date Signed: 11/18/2025 02:13:01 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
03/09/2023 and conducted by Evaluator Michael Tea
COMPLAINT CONTROL NUMBER: 22-AS-20230309095855
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: 194DATE:
11/18/2025
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Miguel CerdaTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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- Faclity staff cannot meet the resident's needs
- Facility staff are forcing resident to receive unnecessary services
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Michael Tea made an unannounced visit to conclude and deliver findings for a complaint investigation. LPA Tea was greeted and granted entry by facility staff and explained the reason for the visit. Executive Director (ED) Mandy Taylor arrived later to assist with the visit.

The Department received a complaint on March 9, 2023. During the investigation, Licensing Program Analyst (LPA) Tea interviewed facility staff and witnesses, and reviewed facility records, resident documentation, and other pertinent information.

It was alleged that facility staff cannot meet the resident’s needs. Per Interviews with six out of six staff revealed that Resident 1 (R1) was identified as one of the most aggressive residents in the memory care unit. Staff consistently reported that R1 frequently exhibited combative behaviors during incontinence care

(Complaint investigation report continued on LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
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-20230309095855
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: 11/18/2025
NARRATIVE
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and bathing. Staff stated it was common for R1 to hit them during attempts to provide care. Review of facility progress notes for R1 corroborated these accounts, documenting multiple incidents of staff being hit and noting additional episodes of aggressive behavior toward other residents. Staff further reported that R1’s family expressed concerns about neglect due to R1 often being observed in bed. However, caregivers’ notes confirmed that R1 routinely did not sleep through the night and was awake for extended periods. Staff stated that R1 would become upset, irritable, or resistant in the mornings when care was provided and would often prefer to remain in bed. All staff interviewed reported that memory care staff provided the best care possible to meet R1’s needs, noting that R1 was a physically large, heavy, and tall individual who required extensive assistance. Staff reported that R1’s health was declining and that the family requested one-to-one care at all times, which facility staff could not provide due to responsibilities for other residents in the memory care unit. Review of R1’s evaluation and needs assessment indicated that R1 required the highest level of assistance with mobility and ambulation, including the assistance of two staff members. R1 also required total assistance with bathing, dressing, and toileting. One staff member reported that at times a third staff member was needed due to R1’s size and behaviors, but staff stated they continued to provide care to the best of their ability.

It was alleged that facility staff are forcing resident to receive unnecessary services. Per a witness alleged that the facility threatened to require approval of medications for R1 or require the family to hire a private caregiver to meet R1’s care needs. Interviews with four out of six staff confirmed that R1 was a high fall risk and that their overall health was declining during their stay. Staff reported R1 would attempt to stand up from their wheelchair or bed without assistance, necessitating close supervision. Due to these safety risks, staff stated they recommended that the family consider a private caregiver to ensure continuous supervision. LPA reviewed R1’s medication records and Outside Agency Documentation, which showed that medication changes were initiated by R1’s family in consultation with R1’s Physician Assistant. Four out of six staff confirmed that the facility followed medical orders as prescribed. No evidence was found indicating the facility forced or manipulated medication decisions. LPA also reviewed R1’s billing records and resident ledger. Records did not show additional charges, or rate increases throughout the year, aside from a standard rent increase at the beginning of the new year. No unexplained or forced charges for private caregiving or additional services were noted.

(Complaint investigation report continued on LIC9099C)
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 22-AS-20230309095855
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: 11/18/2025
NARRATIVE
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Therefore, based on LPA Tea's observations, interviews conducted, and records reviewed the allegations mentioned above have been determined to be UNSUBSTANTIATED meaning that although the allegations may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

No deficiencies cited at this time and an exit interview was conducted with the facility. A copy of the report was provided to the facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Michael Tea
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3