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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005513
Report Date: 03/14/2026
Date Signed: 03/14/2026 02:03:55 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/10/2022 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20220810143732
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: 186DATE:
03/14/2026
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ruby MolinaTIME COMPLETED:
01:25 PM
ALLEGATION(S):
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Resident's personal items are being moved around in his room
Resident had several personal items stolen from his room
Visitors are not screened or temperature checked before entering the facility
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to continue the investigation into the above allegations. LPA was greeted and granted entry into the facility and explained the reason for the visit.
During the course of the investigation, LPA toured the facility and interviewed staff and residents. Regarding the allegations that Visitors are not screened or temperature checked before entering the facility, resident had several personal items stolen from his room and resident's personal items are being moved around in his room, the investigation revealed the following: Two out of two staff state that the Resident 1 (R1) was blind and did not want items moved around. Staff state resident would move things around and then forget about it. Staff interviewed was not aware of item being stolen and due to the age of the complaint there is no documentation present regarding stolen items. Four out of four residents deny missing items in their rooms and verbalize satisfaction with the facility. Three out of three staff state that visitors were screened for illness and/ or covid prior to entering the facility in 2022.CONTINUED ON LIC 9099C DATED 03/14/2026.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2026
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-20220810143732
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CARMEL VILLAGE RETIREMENT COMMUNITY
FACILITY NUMBER: 306005513
VISIT DATE: 03/14/2026
NARRATIVE
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Based on interviews conducted, the allegations are found 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.
An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2