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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005513
Report Date: 03/28/2026
Date Signed: 03/28/2026 12:50:14 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
01/06/2023 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20230106135453
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: 184DATE:
03/28/2026
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Teri McleodTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Facility released private information without authorization
Facility failed to dispense medication
Facility changed hospice company without authorization
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 witnesses as well as reviewed and obtained pertinent documentation such as physician report. Regarding the allegations that facility released private information without authorization, facility failed to dispense medication and facility changed hospice company without authorization, the investigation revealed the following: R1 was enrolled in hospice care with Advantage Hospice. Witness 1 (W1) stated that the facility would be unable to change a hospice company without authorization from the family and indicates conversations were had with the responsible party. Due to the age of the complaint, W1 is unable to remember if the resident ever changed hospice companies before passing. LPA reviewed R1's records and did not find evidence of any other hospice company besides Advantage. W1 denies providing protected health information about R1 to any outside agency. CONTINUED ON LIC 9099C DATED 03/28/2026.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Kimberly Lyman
LICENSING EVALUATOR SIGNATURE:

DATE: 03/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2026
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-20230106135453
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: 03/28/2026
NARRATIVE
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LPA reviewed medication orders for R1. LPA observed orders for four different eye drops but was unable to review medication administration records. Due to the age of the complaint, facility was unable to access the resident's records in the electronic administration record. LPA attempted to interview staff employed during time of complaint but no staff were able to remember R1.



Based on interviews conducted and record review, 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: 03/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2