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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005513
Report Date: 04/23/2026
Date Signed: 04/26/2026 08:38:02 AM

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
10/28/2025 and conducted by Evaluator Eboni Bentley
COMPLAINT CONTROL NUMBER: 22-AS-20251028084748
FACILITY NAME:CARMEL VILLAGE RETIREMENT COMMUNITYFACILITY NUMBER:
306005513
ADMINISTRATOR:MANDY TAYLORFACILITY TYPE:
740
ADDRESS:17077 SAN MATEOTELEPHONE:
(714) 962-6667
CITY:FOUNTAIN VALLEYSTATE: CAZIP CODE:
92708
CAPACITY:220CENSUS: 190DATE:
04/23/2026
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Mandy Taylor - Executive DirectorTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Licensee did not properly address a pest infestation in the facility.
Staff did not communicate with resident’s representative in a timely manner.
Staff did not safeguard residents’ personal belongings.
INVESTIGATION FINDINGS:
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On April 23, 2026, Licensing Program Analyst (LPA) Eboni Bentley arrived at the facility unannounced for a subsequent complaint investigation visit into the above allegations. LPA was greeted and granted entry after stating the purpose of the visit to staff. Executive Director Mandy Taylor was present and assisted with the visit.

During the course of the investigation, LPA reviewed facility documents including: Resident Roster, Staff Roster, Staff Contacts, Staff Schedule, Maintenance and Pest Control logs, Resident Emergency Info & Contact Sheet, Physician's Report, Service Plan, and Resident Property & Valuables form. Interviews were conducted with residents, staff, and witnesses.


CONTINUE TO LIC9099-C......
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026
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-20251028084748
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: 04/23/2026
NARRATIVE
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The investigation revealed the following:
Regarding the allegation, Licensee did not properly address the infestation in the facility, it was alleged that Resident #1 (R1) was experiencing bites on his back and arms from an unidentified type of bug in his room. LPA toured the facility during the initial inspection visit conducted on October 31, 2025, and no immediate health and safety threats were identified. LPA did not observe any bugs in R1’s room and R1 confirmed no bites were visible at the time. A record review revealed R1 reported bugs in their room on September 29, 2025 and staff responded to the room on the same date. Staff #1 (S1) stated the room was inspected but no bugs were found. S1 stated R1 showed them zip lock bags of what R1 indicated were bugs, however S1 stated they were actually earwax and lint. Pictures were taken and provided. LPA interviewed R1 who reported the facility fumigated the room and the bugs were gone but returned shortly after. Resident stated they collected a bug in a zip lock bag and then stated it was later disposed of, therefore LPA was unable to observe the reported evidence. On September 30, 2025, R1 submitted a second request for service and a record review of a Pest Flex vendor invoice revealed the room was fumigated on October 4, 2025.

Regarding the allegation, Staff did not communicate with resident’s representative in a timely manner, it is alleged that the facility did not respond to calls made to the resident’s representative regarding bugs and bites until two weeks after initial contact attempts. During an interview with Witness #1 (W1), it was reported that calls were made to staff and not immediately returned, however no evidence was provided during the investigation. Four out of four staff denied the allegation, stating call requests are returned in a timely manner and a record of all maintenance service requests are documented via LifeLoop software.

Regarding the allegation, Staff did not safeguard residents’ personal belongings, it is alleged that resident’s shirts went missing during the first year of their residency and have not been returned. Four out of four staff interviewed and one witness denied the allegation, stating the resident’s laundry is done off site by family and returned weekly. This was corroborated during an interview with R1 and Witness #2 (W2). A record review of R1's Resident Property & Valuables form revealed the document was blank with no items listed and no evidence of missing items was provided during the investigation.

Based on the observations made, interviews which were conducted, and the records that were reviewed, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are deemed UNSUBSTANTIATED. An exit interview was conducted, and a copy of this report was provided at exit.
SUPERVISORS NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR NAME: Eboni Bentley
LICENSING EVALUATOR SIGNATURE:

DATE: 04/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026
LIC9099 (FAS) - (06/04)
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