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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 12:52:59 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
01/12/2023 and conducted by Evaluator Kimberly Lyman
COMPLAINT CONTROL NUMBER: 22-AS-20230112082829
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:
12:46 PM
MET WITH:Teri McleodTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff are not keeping record of resident's medical information
Staff are not safeguarding resident's personal items
Staff are not keeping resident's restroom clean and sanitary
Staff are using the resident's restroom
Unauthorized staff have access to resident's locked room
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 as well as reviewed and obtained pertinent documentation such as physician report. Regarding the allegations that staff are not keeping record of resident's medical information, staff are not safeguarding resident's personal items, staff are not keeping resident's restroom clean and sanitary and unauthorized staff have access to resident's locked room, the investigation revealed the following: LPA reviewed the available record for R1 including physician report, care plan and pre-placement appraisal. Due to the age of the complaint, LPA is unable to review electronic records. Per interview conducted with former Executive Director, there is not a recollection of a missing item and LPA observed no record of item. LPA is unable to review housekeeping records from time of complaint however, LPA observed the facility to be clean and sanitary on three different occasions. 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-20230112082829
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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Interview with staff indicated staff use public restrooms and not resident rooms. The resident moved out on 01/07/2023. Responsible party came back to resident's room on 01/11/2023 and at that time witnessed evidence that someone had used the restroom. There is no evidence to prove who may have used the restroom once the resident was moved out. All staff have access to resident rooms in the facility in order to provide care and supervision thus would be authorized. Staff interviewed confirm knocking on resident rooms prior to entering. Staff interviewed were unable to recall the resident or circumstances regarding the allegations.
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