306005513-3-18-2026-22-AS-APAO-DSC42K-20260319184315

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005513
Report Date: 03/18/2026
Date Signed: 03/18/2026 03:26:30 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
01/14/2025 and conducted by Evaluator Alvaro Ramirez Jr.

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20250114102443

FACILITY NAME:	CARMEL VILLAGE RETIREMENT COMMUNITY		FACILITY NUMBER:	306005513
ADMINISTRATOR:	JUSTINE M. ORTIZ		FACILITY TYPE:	740
ADDRESS:	17077 SAN MATEO		TELEPHONE:	(714) 962-6667
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	220	CENSUS: 186	DATE:	03/18/2026
		UNANNOUNCED	TIME BEGAN:	12:31 PM
MET WITH:	Mandy Taylor-Executive Director		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Facility did not ensure the health and safety of resident in Memory Care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit to deliver findings on the above allegation received on January 14, 2025. LPA was greeted and granted entry into the facility and met with Executive Director (ED) Mandy Taylor. LPA explained the reason for the visit.

This Department has investigated the complaint alleging that facility did not ensure the health and safety of resident in Memory Care. Regarding the allegation the following was revealed: During the investigation LPA reviewed the Carmel Village Retirement Community Memory Care staff schedule dated January 23, 2025, and March 18, 2026. Per Memory Care staff schedule, on average there are five caregivers and one Medication Technician (MT) for the morning and evening shifts and three caregivers for the night shift. LPA reviewed the Unusual Incident/Injury Report (UIIR) dated January 16, 2025, for Resident 1 (R1). Per UIIR, on January 10, 2025, R1 was found on the floor with her head under the bed. Per UIIR, 911 was called and R1 was transported to the Hospital and admitted for a Urinary Tract Infection (UTI).
CONTINUED ON LIC9099-C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20250114102443

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: 03/18/2026

NARRATIVE

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Documents reviewed include the Carmel Village Retirement Community Service Plan dated January 8, 2025, for R1. Per Service Plan, it states R1 requires one person total assistance by staff members for all mobility/ambulation needs. During the interviews with residents, R2 reported that staff are helpful and attentive and stated that staff will respond quickly when he uses his call button. Per R2, staff work around the clock and reported that staff are meeting his needs. During the interviews with staff, Staff 1 (S1) reported that staff ensure the health and safety of the residents in Memory Care. S2 stated that staff are attentive and reported that the fall was not due to neglect. Per S3, staff do their best to ensure the health and safety of the residents in Memory Care. During the interviews, Witness 1 (W1) reported that she could not say if the fall was due to lack of care and supervision.

Based on the information gathered during the investigation and review of documents obtained, LPA is unable to ascertain if the allegation occurred as reported due to conflicting information. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove or refute the alleged violation occurred; therefore, this allegation is deemed UNSUBSTANTIATED.

For today’s visit, there were no citations issued per Title 22, Division 6 of the California Code of Regulations.

LPA conducted an exit interview with ED Taylor, and a copy of this report was provided to the facility.

SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.
LICENSING EVALUATOR SIGNATURE:	DATE: 03/18/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2026

LIC9099 (FAS) - (06/04)

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