Inspection Reports for
Carmel Village
17077 San Mateo St, Fountain Valley, CA 92708, United States, CA, 92708
Back to Facility ProfileDeficiencies (last 6 years)
Deficiencies (over 6 years)
1.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
58% better than California average
California average: 4 deficiencies/year
Deficiencies per year
4
3
2
1
0
Occupancy
Latest occupancy rate
186% occupied
Based on a March 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 220
Capacity: 220
Deficiencies: 0
Date: Mar 21, 2026
Visit Reason
An unannounced complaint investigation visit was conducted in response to multiple allegations regarding failure to report resident hospitalization, comply with discharge orders, provide supervision, properly store medication, and report resident's true condition to responsible party.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation found all allegations to be unsubstantiated based on interviews and facility observations. Staff confirmed proper medication administration, supervision, and medication storage practices. The mistaken notification of resident death was from the hospital, not the facility.
Report Facts
Facility capacity: 220
Census: 220
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Donald Benton | Administrator | Facility administrator named in report header |
| Alisa Ortiz | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 189
Capacity: 220
Deficiencies: 0
Date: Mar 21, 2026
Visit Reason
An unannounced complaint investigation visit was conducted to investigate multiple allegations received on 2022-10-25 regarding facility conditions, resident services, privacy, postings, resident council meetings, and accommodations.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation found all allegations to be unsubstantiated after touring the facility, interviewing staff and residents, and observing conditions. No obstructions were found, services were provided as agreed, privacy was respected, required postings were present, resident council meetings were held, and reasonable accommodations were provided.
Report Facts
Capacity: 220
Census: 189
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation visit |
| Donald Benton | Administrator | Facility administrator named in the report |
| Alisa Ortiz | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 186
Capacity: 220
Deficiencies: 0
Date: Mar 18, 2026
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation received on January 14, 2025, that the facility did not ensure the health and safety of a resident in Memory Care.
Complaint Details
The complaint alleged failure to ensure the health and safety of a resident in Memory Care. The allegation was unsubstantiated due to conflicting information and lack of preponderance of evidence.
Findings
The investigation included review of staff schedules, incident reports, service plans, and interviews with residents and staff. Conflicting information was found, and there was insufficient evidence to prove or refute the allegation; therefore, the complaint was deemed unsubstantiated. No citations were issued during the visit.
Report Facts
Capacity: 220
Census: 186
Staffing: 5
Staffing: 1
Staffing: 3
Incident Date: Jan 10, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alvaro Ramirez Jr. | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Mandy Taylor | Executive Director | Met with Licensing Program Analyst during the investigation and exit interview |
Inspection Report
Census: 186
Capacity: 220
Deficiencies: 0
Date: Mar 14, 2026
Visit Reason
An unannounced case management visit was conducted in conjunction with multiple complaint visits to review compliance and request documentation related to specific residents.
Complaint Details
The visit was conducted in conjunction with complaint visits numbered 22-AS-20220810143732, 22-AS-20221018074030, 22-AS-20221025101527, 22-AS-20230106135453, and 22-AS-20230112082829.
Findings
During the visit, requested documents pertaining to missing/stolen items, physician reports, care plans, hospice notes, progress notes, and admission agreements for several residents were unavailable and requested to be submitted by a specified date.
Report Facts
Requested documents deadline: Mar 18, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the unannounced case management visit and requested documents |
| Mandy Taylor | Administrator/Director | Facility administrator/director mentioned in the report |
| Ruby Molina | Met with during the inspection visit | |
| Alisa Ortiz | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 186
Capacity: 220
Deficiencies: 0
Date: Mar 14, 2026
Visit Reason
An unannounced complaint investigation was conducted in response to allegations regarding resident personal items being moved or stolen and visitor screening procedures.
Complaint Details
The complaint investigation was unsubstantiated, meaning there was not a preponderance of evidence to prove the alleged violations occurred.
Findings
The investigation found the allegations to be unsubstantiated after interviews with staff and residents revealed no evidence of stolen items or failure to screen visitors for illness or COVID-19.
Report Facts
Capacity: 220
Census: 186
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Lyman | Licensing Program Analyst | Conducted the complaint investigation |
| Donald Benton | Administrator | Facility administrator mentioned in report header |
Inspection Report
Complaint Investigation
Census: 183
Capacity: 220
Deficiencies: 1
Date: Jan 26, 2026
Visit Reason
An unannounced case management visit was conducted to follow up on an SOC341 and Incident Report regarding an alleged physical aggression incident involving Staff #1 and Resident #1.
Complaint Details
The visit was complaint-related following an incident report where Staff #1 was accused of hitting and choking Resident #1. The complaint was substantiated as Staff #1 admitted to inappropriate physical force and failure to report injuries.
Findings
The investigation found that Staff #1 admitted to physically forcing Resident #1 to get out of bed and go to the bathroom despite the resident's refusal, posing an immediate health, safety, and personal rights risk. A deficiency was cited based on these findings.
Deficiencies (1)
Residents in all residential care facilities for the elderly shall have dignity in their personal relationships with staff, residents, and others. This requirement was not met as Staff #1 ignored Resident #1's refusal and physically forced the resident to get out of bed and walk to the bathroom, posing an immediate health, safety, and personal rights risk.
Report Facts
Census: 183
Total Capacity: 220
Deficiencies cited: 1
Plan of Correction Due Date: Jan 27, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mandy Taylor | Executive Director | Met during inspection and involved in exit interview |
| Eboni Bentley | Licensing Program Analyst | Conducted the inspection and investigation |
| Lourdes Montoya | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 183
Capacity: 220
Deficiencies: 1
Date: Jan 26, 2026
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility is in disrepair, specifically that ceilings leak when it rains, staff use buckets to catch water, and repairs have not been made.
Complaint Details
The complaint was substantiated based on interviews, observations, and document review. The allegation involved facility disrepair due to leaking ceilings and unaddressed repairs. The preponderance of evidence standard was met.
Findings
The investigation substantiated the allegation that the facility ceilings leak during rain, with water damage observed on ceiling panels and staff confirming leaks since December 2024 that have not been repaired. A deficiency was cited for failure to maintain the facility in good repair.
Deficiencies (1)
Failure to maintain the facility in a clean, safe, sanitary, and good repair condition as evidenced by water stains and leaks on ceiling panels on the third floor with no repairs made.
Report Facts
Capacity: 220
Census: 183
Deficiency Type: 1
Plan of Correction Due Date: Mar 6, 2026
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eboni Bentley | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Mandy Taylor | Executive Director | Facility representative who assisted with the visit and was present for the exit interview |
Inspection Report
Follow-Up
Census: 191
Capacity: 220
Deficiencies: 0
Date: Dec 18, 2025
Visit Reason
The visit was an unannounced case management health and safety check conducted as a follow-up to an SOC341 and Incident Report received on December 15, 2025.
Findings
During the inspection, no imminent health and safety issues were observed. Interviews were conducted and records reviewed, with no deficiencies explicitly noted in the report.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mandy Taylor | Executive Director | Met with Licensing Program Analyst during inspection and participated in exit interview. |
| Eboni Bentley | Licensing Program Analyst | Conducted the inspection visit and authored the report. |
| Lourdes Montoya | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Follow-Up
Census: 191
Capacity: 220
Deficiencies: 0
Date: Dec 18, 2025
Visit Reason
The inspection visit was an unannounced case management health and safety check conducted as a follow-up to an Incident Report received on November 19, 2025.
Findings
During the inspection, no imminent health and safety issues were observed. Records for a resident were reviewed, and an exit interview was conducted with the Executive Director.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mandy Taylor | Executive Director | Met with during inspection and exit interview. |
| Eboni Bentley | Licensing Program Analyst | Conducted the inspection visit. |
| Lourdes Montoya | Licensing Program Manager | Named in report header. |
Inspection Report
Follow-Up
Census: 187
Capacity: 220
Deficiencies: 0
Date: Nov 25, 2025
Visit Reason
The visit was an unannounced case management follow-up on incident reports received regarding missing personal items reported by two residents in late October 2025.
Complaint Details
The visit was triggered by complaints of missing money and personal items from Resident #1 and Resident #2. Both incidents were reported to the local police department. The investigations by the facility were inconclusive and residents remained dissatisfied.
Findings
The facility conducted internal investigations including staff interviews and camera footage reviews, which were inconclusive. Both residents expressed dissatisfaction with the investigation outcomes. No deficiencies were cited during this visit.
Report Facts
Missing money reported by Resident #1: 117
Missing money reported by Resident #2: 33
Facility capacity: 220
Resident census: 187
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mandy Taylor | Executive Director | Met with Licensing Program Analyst during inspection and provided statements regarding investigation and training plans |
| Eboni Bentley | Licensing Program Analyst | Conducted the unannounced case management visit and interviews |
| Lourdes Montoya | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 194
Capacity: 220
Deficiencies: 0
Date: Nov 18, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on March 9, 2023, alleging that facility staff could not meet the resident's needs and were forcing a resident to receive unnecessary services.
Complaint Details
The complaint alleged that facility staff could not meet the resident's needs and were forcing the resident to receive unnecessary services. The investigation included interviews with staff and review of records. The allegations were found to be unsubstantiated due to lack of preponderance of evidence.
Findings
The investigation found that Resident 1 was aggressive and required extensive assistance, with staff providing the best care possible despite challenges. There was no evidence that the facility forced or manipulated medication decisions or charged for unnecessary services. The allegations were determined to be unsubstantiated.
Report Facts
Capacity: 220
Census: 194
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Tea | Licensing Program Analyst | Conducted the complaint investigation and made observations |
| Mandy Taylor | Executive Director | Assisted with the visit |
Inspection Report
Complaint Investigation
Census: 194
Capacity: 220
Deficiencies: 0
Date: Nov 18, 2025
Visit Reason
The inspection visit was conducted to investigate a complaint alleging that a resident sustained an unexplained injury while in care.
Complaint Details
The complaint alleged that a resident sustained an unexplained injury while in care. The allegation was determined to be unfounded based on interviews and record reviews.
Findings
The investigation found no unusual incident reports or evidence supporting the allegation. Interviews with residents, staff, and a former hospice worker revealed no knowledge or recollection of any unexplained injury. The allegation was determined to be unfounded.
Report Facts
Capacity: 220
Census: 194
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Tea | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Mandy Taylor | Executive Director | Assisted with the inspection visit |
| Alisa Ortiz | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 189
Capacity: 220
Deficiencies: 0
Date: Jul 21, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted to examine allegations that staff left a resident in soiled clothing for extended periods, did not safeguard residents' personal belongings, and that a resident's room was malodorous.
Complaint Details
The complaint investigation was unsubstantiated based on interviews with three staff members and three residents, review of resident files, and observations. No evidence was found to prove the violations occurred.
Findings
The investigation found no evidence supporting the allegations after interviews with staff and residents, a facility tour, and documentation review. The allegations were deemed unsubstantiated and no deficiencies were cited.
Report Facts
Capacity: 220
Census: 189
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Samer Haddadin | Licensing Program Analyst | Conducted the complaint investigation |
| Laura Forman | Memory Care Director | Met with the investigator and granted entry to the facility |
| Donald Benton | Administrator | Facility administrator involved in email communication regarding resident personal belongings |
| Alisa Ortiz | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 188
Capacity: 220
Deficiencies: 0
Date: May 16, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-09-20 regarding a resident sustaining an unexplained fracture and multiple falls due to lack of supervision.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included a resident sustaining an unexplained fracture and multiple falls due to lack of supervision. Interviews and document reviews indicated staff were available and the falls were not due to lack of supervision.
Findings
The investigation found that although the resident sustained a lumbar compression fracture and multiple falls, there was no preponderance of evidence to prove that these incidents were due to lack of care or supervision. The allegations were determined to be unsubstantiated.
Report Facts
Capacity: 220
Census: 188
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donna Gurriere | Licensing Program Analyst | Conducted the complaint investigation and delivered final findings |
| Kianny Soto | Health and Wellness Director | Spoke with Licensing Program Analyst during final findings call |
| Lauren Crocker | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Plan of Correction
Census: 174
Capacity: 220
Deficiencies: 0
Date: May 13, 2025
Visit Reason
The visit was an unannounced Plan of Correction - Deficiencies inspection conducted to follow up on a deficiency issued during the annual inspection on April 22, 2025.
Findings
The inspection found that the facility complied with the terms of the Plan of Corrections, including proper maintenance and operation of resident bathrooms and water temperature within regulatory limits.
Report Facts
Water temperature range: 109.2
Water temperature range: 119.3
Resident apartment units inspected: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mandy Taylor | Administrator/Executive Director | Met during inspection and exit interview |
| Eboni Bentley | Licensing Program Analyst | Conducted the Plan of Correction inspection |
| Jessica Cho | Licensing Program Analyst | Conducted the prior annual inspection on April 22, 2025 |
Inspection Report
Complaint Investigation
Capacity: 220
Deficiencies: 0
Date: Apr 30, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to multiple allegations including medication mismanagement, inadequate staff training, facility cleanliness, lighting, safety, and resident care concerns.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included medication mismanagement, inadequate staff training, poor laundry room maintenance, disturbed resident sleep, inadequate lighting, insufficient staffing, failure to provide test results, facility disrepair, and unsafe environment. Interviews and observations did not support these claims.
Findings
The investigation found all allegations to be unsubstantiated based on interviews with staff and residents, facility walkthroughs, and record reviews. No deficiencies were cited during the visit.
Report Facts
Facility capacity: 220
Number of staff interviewed: 6
Number of resident interviews: 6
Staff response time to calls: 12
Staff response time to calls: 25
Staff response time to calls: 15
Staff response time to calls: 20
Training duration: 8
Employment duration: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Samer Haddadin | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Donald Benton | Administrator | Facility Administrator present during exit interview |
| Alisa Ortiz | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Annual Inspection
Census: 173
Capacity: 220
Deficiencies: 1
Date: Apr 22, 2025
Visit Reason
The inspection was an unannounced Required 1 Year Annual Inspection conducted to evaluate compliance with licensing requirements for the Carmel Village Retirement Community facility.
Findings
The inspection found that the facility generally met licensing requirements including proper maintenance of resident apartments, kitchen, and safety equipment. However, four out of sixteen resident apartment bathrooms had hot water temperatures exceeding the allowed maximum of 120 degrees Fahrenheit, posing an immediate health risk. Additionally, a strong odor was noted in one apartment unit. A deficiency was cited and a Technical Violation issued.
Deficiencies (1)
Hot water temperatures in four out of sixteen resident apartment bathrooms exceeded 120 degrees Fahrenheit, posing an immediate health, safety, or personal rights risk to persons in care.
Report Facts
Residents receiving hospice care: 13
Residents interviewed: 16
Staff interviewed: 4
Resident files reviewed: 15
Staff files reviewed: 4
Hot water temperatures measured: 4
Fire extinguisher service date: Jul 1, 2024
Smoke/carbon monoxide detector test date: Nov 19, 2024
Plan of Correction due date: Apr 23, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mandy Taylor | Executive Director | Assisted with the annual inspection and participated in exit interview |
| Jessica Cho | Licensing Program Analyst | Conducted the inspection and signed the report |
| Edward Kim | Licensing Program Analyst | Conducted the inspection |
| Justine M. Ortiz | Administrator/Director | Facility Administrator named in report header |
Inspection Report
Complaint Investigation
Census: 167
Capacity: 220
Deficiencies: 0
Date: Apr 21, 2025
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 04/20/2022 regarding staff neglect, delayed response to resident calls, and a resident being dropped while assisted in the shower.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff neglect causing a pressure ulcer, untimely response to resident calls, and dropping a resident in the shower. Interviews and record reviews did not support these claims.
Findings
After reviewing resident records and conducting interviews with six residents and three staff members, the allegations were found to be unsubstantiated due to lack of preponderance of evidence. Residents and staff denied the allegations and stated that calls for assistance were answered in a timely manner.
Report Facts
Capacity: 220
Census: 167
Resident interviews: 6
Staff interviews: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mandy Taylor | LVN Executive Director | Met with during the investigation and exit interview |
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the complaint investigation |
| Samer Haddadin | Conducted resident and staff interviews |
Inspection Report
Complaint Investigation
Census: 167
Capacity: 220
Deficiencies: 1
Date: Apr 21, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff mismanaged a resident's medication.
Complaint Details
The complaint was substantiated. The allegation was that staff mismanaged a resident's medication by giving medication from another resident's supply. The investigation included file reviews and interviews with residents, staff, and family members.
Findings
The investigation found that a resident was accidentally given medication from another resident's supply, though the dosage was the same. The allegation was substantiated based on record reviews and interviews, resulting in a cited deficiency related to medication storage regulations.
Deficiencies (1)
Failure to store each resident's medication in its originally received container, with medications transferred between containers.
Report Facts
Capacity: 220
Census: 167
Deficiency Type B: 1
Plan of Correction Due Date: May 5, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RoseMarie Ruppert | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Pam Munday | Regional Vice President of Operations | Met with during exit interview; did not sign the report |
| Mandy Taylor | Executive Director, LVN | Met with during initial visit and explained the purpose of the visit |
| Alisa Ortiz | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Follow-Up
Census: 180
Capacity: 220
Deficiencies: 0
Date: Mar 5, 2025
Visit Reason
The visit was an unannounced follow-up to a death report and incident report concerning Resident #1, to review the circumstances and documentation related to the incident.
Findings
No health and safety violations were noted during the visit. The incident involved a resident found unresponsive with food in their mouth, CPR was performed, and the resident later passed away at the hospital.
Report Facts
Incident Report Date: Feb 25, 2025
Progress Notes Date Range: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Cho | Licensing Program Analyst | Conducted the follow-up visit and evaluation |
| Justine Ortiz | Executive Director | Met with Licensing Program Analyst during the visit and involved in incident discussion |
Inspection Report
Complaint Investigation
Capacity: 220
Deficiencies: 1
Date: Feb 28, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff was yelling at a resident.
Complaint Details
The complaint was substantiated. One staff member was found to have yelled at a resident. The staff member had prior reprimands and was terminated. The deficiency was cited under Title 22, Division 6, Chapter 8 of the California Code of Regulations.
Findings
The investigation included interviews with staff and residents and a review of staff files. One staff interview corroborated the allegation, while two denied it. The allegation was substantiated based on evidence including prior disciplinary actions against the staff member involved.
Deficiencies (1)
Facility employee yelled at resident, violating residents' personal rights to dignity in their relationships with staff.
Report Facts
Facility capacity: 220
Deficiency type count: 1
Probation duration: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donald Benton | Administrator | Facility administrator who received the report and appeal rights |
| Samer Haddadin | Licensing Evaluator | Conducted the complaint investigation and authored the report |
| Alisa Ortiz | Supervisor | Supervisor overseeing the licensing evaluation |
| S1 | Staff member | Staff member who was reprimanded, put on probation, and terminated for yelling at residents |
Inspection Report
Complaint Investigation
Census: 182
Capacity: 220
Deficiencies: 0
Date: Feb 4, 2025
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that staff intimidated a resident at Carmel Village Retirement Community.
Complaint Details
The complaint alleged staff intimidation of a resident. Interviews with three staff and three residents showed no support for the allegation except one staff interview confirming yelling that was not threatening. Residents had cognitive impairments limiting comprehension. The allegation was unsubstantiated.
Findings
The investigation included interviews with staff and residents and a review of records. The allegation was found to be unsubstantiated as evidence did not support that staff intimidated the resident; one staff member was observed yelling but not in an intimidating manner.
Report Facts
Capacity: 220
Census: 182
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Samer Haddadin | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Donald Benton | Administrator | Facility administrator named in the report |
Inspection Report
Complaint Investigation
Census: 188
Capacity: 220
Deficiencies: 0
Date: Dec 11, 2024
Visit Reason
This unannounced investigation inspection was conducted in response to a complaint received on 2024-12-04 alleging that the facility is malodorous.
Complaint Details
Complaint received on 2024-12-04 alleging the facility is malodorous. Investigation found insufficient evidence to substantiate the complaint; it was deemed unsubstantiated.
Findings
The Licensing Program Analyst toured the facility and conducted interviews with residents, finding no malodorous smells. Based on observations and interviews, there was insufficient evidence to support the allegation, and the complaint was unsubstantiated.
Report Facts
Census: 188
Total Capacity: 220
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Justine M. Ortiz | Executive Director | Met with Licensing Program Analyst during the investigation |
| Dwayne L Mason | Licensing Program Analyst | Conducted the complaint investigation |
Inspection Report
Census: 179
Capacity: 220
Deficiencies: 0
Date: Nov 5, 2024
Visit Reason
The visit was a Case Management visit conducted to follow up on incident reports received by the Department.
Findings
Based on the visit, no deficiencies were issued. Staff interviews indicated understaffing concerns, but the facility uses a staffing agency to fill call-outs and is currently hiring.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laura Foreman | Memory Care Director | Met with during the inspection and interviewed regarding staffing and incident follow-up. |
Inspection Report
Complaint Investigation
Census: 180
Capacity: 220
Deficiencies: 0
Date: Aug 21, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that facility staff did not ensure resident's food was protected against vermin.
Complaint Details
The complaint alleged that facility staff did not ensure resident's food was protected against vermin. The allegation was found to be unfounded, meaning it was false, could not have happened, or was without reasonable basis.
Findings
The investigation found the allegation to be unfounded after interviews with residents and staff, review of resident files, and pest control service records showed no current vermin issues and continuous pest control maintenance.
Report Facts
Residents interviewed: 13
Pest control service frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ruth Martinez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Justine M. Ortiz | Executive Director | Facility representative met during the investigation |
Inspection Report
Complaint Investigation
Census: 173
Capacity: 220
Deficiencies: 0
Date: Jun 14, 2024
Visit Reason
An unannounced complaint investigation was conducted following a complaint alleging that staff did not prevent a resident from sustaining multiple falls while in care.
Complaint Details
The complaint alleged that staff did not prevent a resident from sustaining multiple falls, with the resident sustaining five falls within a thirty-day period. The allegation was unsubstantiated based on the preponderance of evidence.
Findings
The investigation found that the resident was assessed as high risk for falls and sustained multiple unwitnessed falls despite preventive measures. Staff were monitoring the resident continuously, and the allegation was determined to be unsubstantiated due to insufficient evidence that staff failed to prevent the falls.
Report Facts
Falls sustained by resident: 5
Census: 173
Total capacity: 220
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Justine Ortiz | Administrator | Met during the visit and participated in exit interview. |
| RoseMarie Ruppert | Licensing Evaluator | Conducted the complaint investigation. |
| Alisa Ortiz | Licensing Program Manager | Supervised the complaint investigation. |
Inspection Report
Complaint Investigation
Census: 173
Capacity: 220
Deficiencies: 0
Date: Jun 14, 2024
Visit Reason
An unannounced complaint investigation was conducted regarding allegations that staff were not properly addressing pest infestation in the facility.
Complaint Details
The complaint alleged that staff were not properly addressing pest infestation. The investigation included interviews with residents and staff, review of resident files and maintenance invoices, and observation. The allegation was found unsubstantiated due to lack of evidence.
Findings
The investigation found no evidence of pest infestation in the facility. Interviews with residents and staff, review of pest control records, and observation of the resident's room showed no signs of fleas or mites. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 220
Census: 173
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Tea | Licensing Evaluator | Conducted the complaint investigation |
| Alisa Ortiz | Licensing Program Manager | Supervised the complaint investigation |
| Justine Ortiz | Executive Director | Met with investigators during the inspection |
Inspection Report
Annual Inspection
Census: 184
Capacity: 220
Deficiencies: 2
Date: Apr 11, 2024
Visit Reason
An unannounced visit was conducted for the purpose of performing an annual required evaluation of the Carmel Village Retirement Community facility.
Findings
The facility was found to be operating within allowed capacity with clean and well-maintained accommodations, proper food storage, and safety measures in place. However, deficiencies were cited related to missing health screenings and tuberculosis tests in six of ten personnel files, and unsafe storage of a knife in a resident's bedroom with dementia.
Deficiencies (2)
Six of ten personnel files reviewed did not have health screening and tuberculosis test screening.
During inspection, a knife was observed near the kitchen sink in a resident's bedroom with dementia, posing a potential danger.
Report Facts
Residents receiving hospice care: 34
Personnel files missing health screening: 6
Plan of Correction Due Date: Apr 18, 2024
Plan of Correction Due Date: Apr 15, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Justine Ortiz | Administrator | Named in relation to deficiencies regarding missing health screenings and unsafe storage of items. |
| Alfonso Cerda | Maintenance Director | Involved in inspection tour and removal of unsafe items. |
| Laura Sanchez | Health and Wellness Director | Met with Licensing Program Analysts during inspection. |
Inspection Report
Follow-Up
Census: 170
Capacity: 220
Deficiencies: 0
Date: Nov 2, 2023
Visit Reason
The visit was conducted as a follow-up on a self-reported incident involving resident R1 that occurred on October 20, 2023.
Findings
The Licensing Program Analyst interviewed staff, reviewed documents, toured the facility, and observed the resident. No injuries were noted from the incident, and corrective actions including 24-hour caregiver placement, door code changes, and staff training on elopement and code safety were implemented.
Report Facts
Incident date: Oct 20, 2023
Report date: Nov 2, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laura Sanchez | Resident Care Coordinator | Met with Licensing Program Analyst during visit and evaluated resident |
| Terrie Sherrell | Regional Director of Health and Wellness | Met with Licensing Program Analyst during visit |
| Charles J Eusey III | Administrator | Facility administrator named in report header |
| Ruth Martinez | Licensing Program Analyst | Conducted the case management visit |
| Armando J Lucero | Supervisor | Supervisor named in report |
Inspection Report
Complaint Investigation
Census: 177
Capacity: 220
Deficiencies: 0
Date: Aug 3, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted to address allegations that the facility failed to notify the responsible party of a medical emergency and that a resident's bedroom was left in unsanitary condition.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included failure to notify the responsible party of a medical emergency and unsanitary conditions in a resident's bedroom. Evidence did not support these claims.
Findings
The investigation found both allegations to be unsubstantiated based on interviews, documentation review, and observations, with no deficiencies cited during the visit.
Report Facts
Capacity: 220
Census: 177
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosie Quiroz | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| Terrie Sherrell | Regional Director of Health and Wellness | Participated in exit interview and was provided a copy of the report |
| Nilab Popal | Business Office Manager | Met with Licensing Program Analyst during the visit |
| Laura Sanchez | Health Wellness Director | Met with Licensing Program Analyst during the visit |
Inspection Report
Census: 178
Capacity: 220
Deficiencies: 0
Date: Jul 21, 2023
Visit Reason
This unannounced Case Management – Other inspection visit was conducted to deliver amended findings for multiple complaint control numbers based on report corrections and complaint follow-up investigations requiring interviews, document reviews, and facility observations.
Complaint Details
The inspection was related to delivering amended findings for complaint control numbers 22-AS-20221011152147, 22-AS-20220929163554, 22-AS-20201002130659, and 22-AS-20210324151302 based on complaint follow-up investigations.
Findings
During the inspection, the Licensing Program Analyst toured the memory care unit and discussed previously delivered and amended findings with the Administrator. Amended reports were delivered and discussed in an exit interview.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charles J Eusey III | Administrator | Met during inspection and discussed findings. |
| Laura Sanchez | Health and Wellness Director | Met during inspection. |
| Rosie Quiroz | Licensing Program Analyst | Conducted the inspection and delivered amended findings. |
| Alisa Ortiz | Supervisor | Named as supervisor in report. |
Inspection Report
Complaint Investigation
Census: 173
Capacity: 220
Deficiencies: 0
Date: May 17, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate the allegation that personal rights were being violated at the facility.
Complaint Details
The complaint alleged that a resident's personal rights were violated due to not receiving a refund upon moving out. The investigation confirmed the resident received 80% of the preadmission fee refund and an additional refund after a delay. The allegation was determined to be unfounded.
Findings
The investigation found that the allegation of personal rights violation was unfounded. The resident received the required refund, although it was delayed due to accounting issues, and no deficiencies were cited during the visit.
Report Facts
Refund amount: 2800
Refund amount: 448.53
Refund percentage: 80
Complaint receipt date: Mar 15, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rosie Quiroz | Licensing Program Analyst | Conducted the complaint investigation |
| Alisa Ortiz | Licensing Program Manager | Conducted the complaint investigation |
| Charles Eusey | Executive Director | Facility representative met during investigation |
| Donald Benton | Former Administrator | Provided information regarding refund processing |
Inspection Report
Complaint Investigation
Census: 173
Capacity: 220
Deficiencies: 1
Date: May 17, 2023
Visit Reason
An unannounced visit was conducted to investigate a case management deficiency related to complaint control number 22-AS-20220207122742.
Complaint Details
The visit was complaint-related under complaint control number 22-AS-20220207122742. No substantiation status was provided.
Findings
A Technical Violation LIC 9102 was issued for General Food Services Requirement 87555(b)(17) due to the facility's inability to provide the dietician's last nutrition report during the investigation.
Deficiencies (1)
Failure to provide dietician's last nutrition report as requested during investigation.
Report Facts
Facility capacity: 220
Census: 173
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charles J Eusey III | Administrator | Met with Licensing Program Analyst during the inspection and involved in findings. |
| Rosie Quiroz | Licensing Program Analyst | Conducted the unannounced visit and investigation. |
| Alisa Ortiz | Supervisor | Supervisor overseeing the licensing evaluation. |
Inspection Report
Complaint Investigation
Census: 173
Capacity: 220
Deficiencies: 0
Date: May 17, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate the allegation that the facility was not following the admission agreement, specifically regarding charging additional fees without notice.
Complaint Details
The complaint alleged that the facility was not following the admission agreement by charging Resident 1 additional fees without notice. The investigation revealed that notices were properly given and fees were increased only after the required advance notice. The allegation was found to be unfounded.
Findings
The investigation found that the facility provided required advance notice of rent increases and additional fees to residents and their responsible parties. The allegation that the facility was not following the admission agreement was determined to be unfounded. No deficiencies were cited during the visit.
Report Facts
Capacity: 220
Census: 173
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charles Eusey | Executive Director | Met during the investigation and exit interview |
| Rosie Quiroz | Licensing Program Analyst | Conducted the complaint investigation |
| Alisa Ortiz | Licensing Program Manager | Conducted the complaint investigation and supervised |
Inspection Report
Complaint Investigation
Capacity: 220
Deficiencies: 0
Date: May 17, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate the allegation that the facility elevator was not accessible to residents due to being in disrepair.
Complaint Details
The complaint allegation that the facility elevator was not accessible to residents due to being in disrepair was investigated and found to be unfounded based on interviews, observations, and evidence.
Findings
The investigation found that the facility had notified all parties of planned elevator repairs, implemented no tray charges, provided escorting and snacks to affected residents, and retained two operational elevators during repairs. The allegation was determined to be unfounded with no deficiencies cited.
Report Facts
Facility capacity: 220
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charles J Eusey III | Administrator | Met during investigation and exit interview |
| Laura Sanchez | Health and Wellness Director | Met during investigation and exit interview |
| Rosie Quiroz | Licensing Program Analyst | Conducted the complaint investigation |
| Alisa Ortiz | Licensing Program Manager | Conducted the complaint investigation and supervised |
Inspection Report
Complaint Investigation
Census: 173
Capacity: 220
Deficiencies: 0
Date: May 17, 2023
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation regarding an allegation that the facility had not eradicated insect infestation.
Complaint Details
The complaint alleged that the facility had not eradicated insect infestation. The investigation included document review, staff and resident interviews, and facility inspection. The allegation was found to be unfounded, meaning it was false or without reasonable basis.
Findings
The investigation found that the facility had a contracted exterminator providing routine monthly pest control services and no evidence of pest activity was observed during the visit or reported by staff and residents. The allegation was determined to be unfounded with no deficiencies cited.
Report Facts
Capacity: 220
Census: 173
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charles Eusey | Administrator | Met during inspection and exit interview |
| Laura Sanchez | Health and Wellness Director | Met during inspection and exit interview |
| Rosie Quiroz | Licensing Evaluator | Conducted the complaint investigation |
| Alisa Ortiz | Licensing Program Manager | Conducted the complaint investigation and supervised |
Inspection Report
Complaint Investigation
Capacity: 220
Deficiencies: 0
Date: May 17, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations that the facility was not providing a special diet as ordered by the physician and that an employee ate a resident's personal ice cream stored in the facility freezer.
Complaint Details
The complaint investigation was unsubstantiated based on interviews, documentation review, and observations. The allegations included failure to provide a special diet and violation of personal rights by staff consuming resident's ice cream. The evidence did not prove the alleged violations occurred.
Findings
The investigation found that the resident was served jello as dessert and alternative dessert options were available. The resident purchased their own ice cream which was reportedly eaten by a staff member, but evidence was insufficient to substantiate the allegations. The allegations were found to be unsubstantiated and no deficiencies were cited during the visit.
Report Facts
Facility capacity: 220
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charles Eusey | Administrator | Met with investigators during the complaint investigation and exit interview |
| Rosie Quiroz | Licensing Program Analyst | Conducted the complaint investigation |
| Alisa Ortiz | Licensing Program Manager | Conducted the complaint investigation and supervised the visit |
Inspection Report
Complaint Investigation
Census: 173
Capacity: 220
Deficiencies: 0
Date: May 17, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate the allegation that staff gave out a resident's phone number without permission.
Complaint Details
The complaint alleged that staff gave out a resident's phone number without permission. The allegation was found to be unsubstantiated based on interviews and evidence gathered during the investigation.
Findings
The investigation found that the resident's phone number had been previously shared and was not new information. Interviews with residents and staff indicated no unauthorized disclosure beyond what was already known. The allegation was found to be unsubstantiated and no deficiencies were cited.
Report Facts
Capacity: 220
Census: 173
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charles Eusey | Administrator | Met during the investigation and exit interview |
| Laura Sanchez | Health and Wellness Director | Met during the investigation and exit interview |
| Rosie Quiroz | Licensing Program Analyst | Conducted the complaint investigation |
| Alisa Ortiz | Licensing Program Manager | Conducted the complaint investigation and supervised |
Inspection Report
Complaint Investigation
Census: 173
Capacity: 220
Deficiencies: 0
Date: May 17, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate the allegation that the facility failed to keep indoor passageways free of obstruction which resulted in a resident's fall.
Complaint Details
The complaint alleged that the facility failed to keep indoor passageways free of obstruction which resulted in a resident's fall. The allegation was unsubstantiated based on interviews, documentation review, and observations.
Findings
The investigation found that the resident's fall was unrelated to any obstruction in the facility's indoor passageways. Although staff had been using the stairwell for storage, this was not linked to the fall incident. The allegation was found to be unsubstantiated and no deficiencies were cited.
Report Facts
Facility capacity: 220
Census: 173
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charles Eusey | Administrator | Met during the investigation and exit interview |
| Laura Sanchez | Health and Wellness Director | Met during the investigation and exit interview |
| Rosie Quiroz | Licensing Program Analyst | Conducted the complaint investigation |
| Alisa Ortiz | Licensing Program Manager | Conducted the complaint investigation and supervised |
Inspection Report
Complaint Investigation
Census: 173
Capacity: 220
Deficiencies: 0
Date: May 17, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate the allegation that staff are unable to meet the resident's needs while in care.
Complaint Details
The complaint alleged that staff were unable to meet the resident's needs while in care. The allegation was found to be unsubstantiated based on interviews, documentation review, and observations.
Findings
The investigation found that although the resident had concerns about staff's ability to assist during emergencies, staff were trained and aware of procedures, and the allegation was unsubstantiated. No deficiencies were cited during the visit.
Report Facts
Capacity: 220
Census: 173
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charles Eusey | Administrator | Met during the investigation and exit interview |
| Laura Sanchez | Health and Wellness Director | Met during the investigation and exit interview |
| Rosie Quiroz | Licensing Evaluator | Conducted the complaint investigation |
| Alisa Ortiz | Licensing Program Manager | Conducted the complaint investigation and supervised |
Inspection Report
Complaint Investigation
Census: 178
Capacity: 220
Deficiencies: 0
Date: Mar 15, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted to follow up on an allegation that the facility did not provide adequate supervision resulting in a resident jumping out of a window.
Complaint Details
The complaint alleged inadequate supervision resulting in a resident jumping out of a window. The allegation was found to be unsubstantiated after investigation.
Findings
The investigation found that on August 31, 2022, a resident jumped out of a second story window due to hallucinations and fear. The facility had window locks which the resident was able to bypass. After the incident, additional locks were installed and staff were instructed to check windows regularly. The allegation was found to be unsubstantiated due to insufficient evidence that the facility failed in supervision.
Report Facts
Facility capacity: 220
Resident census: 178
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charles Eusey | Administrator | Met with Licensing Program Analyst during the investigation and exit interview |
| Rosie Quiroz | Licensing Program Analyst | Conducted the complaint investigation visit |
| Laura Sanchez | Health and Wellness Director | Participated in the exit interview |
| Alisa Ortiz | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 178
Capacity: 220
Deficiencies: 1
Date: Mar 15, 2023
Visit Reason
An unannounced visit was conducted by Licensing Program Analyst Rosie Quiroz to investigate a case management deficiency related to a complaint under control number 22-AS-20220901132618.
Complaint Details
The visit was triggered by a complaint investigation under control number 22-AS-20220901132618. The deficiency was substantiated based on staff interviews and documentation review.
Findings
The investigation found that Resident 1 exhibited unusual behavior such as sitting and crawling on the ground, but no written re-appraisal was conducted to assess the change in condition, which is a violation of California Code of Regulations Title 22 Division 6.
Deficiencies (1)
Failure to conduct a reappraisal when there was a significant change in Resident 1's condition, as required by CCR 87463(c).
Report Facts
Staff interviewed: 8
Staff reporting unusual behavior: 5
Plan of Correction due date: Mar 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charles J Eusey III | Administrator | Met during the investigation and exit interview |
| Laura Sanchez | Health and Wellness Director | Met during the investigation and exit interview |
| Rosie Quiroz | Licensing Program Analyst | Conducted the inspection and investigation |
| Alisa Ortiz | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 180
Capacity: 220
Deficiencies: 1
Date: Aug 4, 2022
Visit Reason
An unannounced complaint investigation visit was conducted to address the allegation that the facility was not reporting COVID-19 positive cases in a timely manner.
Complaint Details
The complaint was substantiated based on evidence that the facility did not report COVID-19 positive cases timely. The allegation was that the facility was not reporting COVID-19 positive cases, which was confirmed by interviews and document review.
Findings
The investigation found that the facility failed to report COVID-19 positive cases timely to Community Care Licensing, substantiating the allegation. Documentation and interviews confirmed delayed reporting of 8 COVID-19 cases past the required 24-hour timeframe.
Deficiencies (1)
Failure to report epidemic outbreaks such as COVID-19 positive cases within 24 hours to the licensing agency and local health officer as required by CCR 87211(a)(2).
Report Facts
COVID-19 positive cases reported late: 8
Plan of Correction due date: Aug 11, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Charles Eusey | Executive Director | Met during investigation and exit interview; named in findings related to reporting deficiencies. |
| Nilab Popal | Business Office Manager | Met during investigation and discussed purpose of visit. |
| Rosie Quiroz | Licensing Program Analyst | Conducted the complaint investigation visit. |
Inspection Report
Annual Inspection
Census: 167
Capacity: 220
Deficiencies: 0
Date: Apr 19, 2022
Visit Reason
Licensing Program Analyst Andrea Mendivil conducted an unannounced visit for the purpose of conducting an annual visit at Carmel Village Retirement Community Facility.
Findings
The facility was observed to be clean, sanitary, and well maintained with residents appearing happy and well taken care of. No deficiencies were noted during the visit. The facility has approved mitigation plans, emergency supplies, and follows COVID-19 protocols including vaccination and testing plans.
Report Facts
Capacity: 220
Census: 167
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Chuck Eusey | Executive Director | Accompanied Licensing Program Analyst during facility tour |
| Alfonso Cerda | Maintenance | Accompanied Licensing Program Analyst during facility tour |
| Karen Ashley | Health Services Director | Accompanied Licensing Program Analyst during facility tour |
Inspection Report
Capacity: 220
Deficiencies: 0
Date: Mar 2, 2022
Visit Reason
Licensing Program Analyst Kevin Saborit-Guasch made an unannounced visit to conduct a case management and health and safety check at the facility.
Findings
During the visit, no immediate threat to the health and safety of residents was observed and no citations were issued.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kevin Saborit-Guasch | Licensing Program Analyst | Conducted the unannounced visit and exit interview. |
| Cash Benton | Administrator | Met with Licensing Program Analyst during the visit. |
Inspection Report
Census: 160
Capacity: 220
Deficiencies: 0
Date: Nov 30, 2021
Visit Reason
An unannounced case management visit was made to follow up on an incident report dated 11/19/2021 involving a resident found laying on his bedroom floor.
Findings
The resident was transported to hospitals for physical therapy and is currently at a skilled nursing facility receiving therapy with plans to return to the community. No further action was required.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Donald Benton | Administrator | Met with Licensing Program Analyst during the visit and provided information about the resident's status. |
Report
April 22, 2025
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