306005513-3-21-2026-22-AS-APAO-DSH4FB-20260324190341

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005513
Report Date: 03/21/2026
Date Signed: 03/21/2026 02:07:39 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
10/18/2022 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20221018074030

FACILITY NAME:	CARMEL VILLAGE RETIREMENT COMMUNITY		FACILITY NUMBER:	306005513
ADMINISTRATOR:	BENTON, DONALD		FACILITY TYPE:	740
ADDRESS:	17077 SAN MATEO		TELEPHONE:	(714) 962-6667
CITY:	FOUNTAIN VALLEY	STATE: CA	ZIP CODE:	92708
CAPACITY:	220	CENSUS:	DATE:	03/21/2026
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Ruby Molina		TIME COMPLETED:	01:16 PM

ALLEGATION(S):

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Facility failed to report resident's hospitalization to family
Facility failed to comply with resident's discharge orders
Facility failed to provide supervision to resident resulting in resident pulling catheter out
Facility failed to properly store resident's medication
Facility staff failed to report resident's true condition to responsible party

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced complaint visit to deliver findings on 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, the department toured the facility and interviewed staff and witness. Regarding the allegation that Facility failed to report resident's hospitalization to family, the investigation revealed the following: Resident 1 (R1) had several hospitalizations as the resident was declining. Witness 1 (W1) states the resident's responsible party was always notified when the resident was sent out to the hospital. W1 indicates resident had instances of being transferred to a different hospital once admitted and sometimes the faciliy had to track down the resident. W1 confirms speaking with family regarding hospitalizations.
Regarding the allegation that facility failed to comply with resident's discharge orders, the investigation revealed the following: W1 states that all prescribed medications were administered to the resident. W1 does not recall specific medications due to the age. CONTINED ON LIC 9099C DATED 03/21/2026

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:	DATE: 03/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2026

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-20221018074030

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: 03/21/2026

NARRATIVE

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W1 states that all prescribed medications were administered to the resident. W1 does not recall specific medications due to the age of the complaint but denies facility wouldn't administer non-prescribed medication. Facility staff confirm physician orders are followed. LPA did not observe an order for Vitamin B on the resident's medication orders.
Regarding the allegation that facility failed to provide supervision to resident resulting in resident pulling catheter out, the investigation revealed the following: Responsible Party and W1 confirm resident had a sitter at the facility as well as staff checking in every 2 hours. Once it was observed that the resident had pulled out the catheter, medical attention was sought immediately. The resident did not return to the facility after being sent out on this occasion due to declining health. Two out of two staff confirm residents on care are checked every 2 hours.
Regarding the allegation that facility failed to properly store resident's medication, the investigation revealed the following: W1 states medications are delivered to the medication room and not to a resident's room. W1 does not recall an incident where insulin was observed to be in the resident's room especially since the resident was on med management. Two out of two staff confirm medications are not delivered to resident rooms.
Regarding the allegation that facility staff failed to report resident's true condition to responsible party, the investigation revealed the following: W1 confirms sending condolences to the resident's family being inadvertently informed that the resident had passed. The hospital had mistakenly notified about the passing of the resident as the resident had not passed. The family was understandably upset but the notification came from the hospital and not the facility. W1 stated following what had been told to the witness.

Due to the age of the complaint, LPA is unable to review parts of the resident's electronic medical record and staff interviewed do not remember the resident.

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: 03/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2026

LIC9099 (FAS) - (06/04)

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