306005513-3-21-2026-22-AS-APAO-DSH4ZV-20260324193321

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005513
Report Date: 03/21/2026
Date Signed: 03/21/2026 02:09:14 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
10/25/2022 and conducted by Evaluator Kimberly Lyman

COMPLAINT CONTROL NUMBER: 22-AS-20221025101527

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: 189	DATE:	03/21/2026
		UNANNOUNCED	TIME BEGAN:	01:16 PM
MET WITH:	Ruby Molina		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff are not keeping indoor passageways and stairways free of obstruction
Staff are not providing services to resident as agreed upon in resident's Admissions Agreement
Staff are not according resident(s) privacy while in care
Staff do not prominently post information in areas accessible to resident(s) in care
Staff are prohibiting residents from holding Resident Council meetings
Facility does not provide reasonable accommodations(s) for resident in care

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 allegation that staff are not keeping indoor passageways and stairways free of obstruction, the investigation revealed the following: Two out of two staff and four out of four residents deny seeing any areas of the facility with obstructions. LPA toured the facility on two different occasions and did not observe any obstructions.
Regarding the allegation that staff are not providing services to resident as agreed upon in resident's Admissions Agreement: Admission agreement dated 11/15/2021 for Resident 1 (R1) does not specify how often staff will check in on the resident. However, two out of two staff confirm that staff check residents every 2 hours when on care.
CONTINUED 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-20221025101527

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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Regarding the allegation that staff are not according resident(s) privacy while in care: Four out of four residents and two out of two staff confirm staff are respectful and announce themselves before entering a resident's apartment. Two out of two staff indicate staff wear earpieces connected to their pagers and resident names are not mentioned over the system. Care staff communicate room numbers only and LPA observed this during the investigation.
Regarding the allegation that staff do not prominently post information in areas accessible to resident(s) in care: LPA observed all required postings in common area of the facility. All postings were accessible to residents and in an appropriate font.
Regarding the allegation that staff are prohibiting residents from holding Resident Council meetings: Five out of five residents and two out of two staff confirm resident council meetings have been conducted.
Regarding the allegation that facility does not provide reasonable accommodations(s) for resident in care: LPA observed postings and resident notices in elevators and common areas to be at appropriate heights and accessible to residents in care throughout the facility.

Based on interviews conducted and observation, 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: 03/21/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/21/2026

LIC9099 (FAS) - (06/04)

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