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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005756
Report Date: 11/17/2022
Date Signed: 11/17/2022 03:32:19 PM

Document Has Been Signed on 11/17/2022 03:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CARVER SENIOR HOMES 1FACILITY NUMBER:
306005756
ADMINISTRATOR:DE GUZMAN, VIRGILIOFACILITY TYPE:
740
ADDRESS:16202 CAIRO CIRCLETELEPHONE:
(714) 572-8821
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6CENSUS: 5DATE:
11/17/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Isaiah Tashiro - Administrator TIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced case management visit at Carver Senior Homes 1 LPA was greeted, and explained the reason for the visit. LPA Mendivil was met with Isaiah Tashiro

The purpose of today's visit was to deliver complaint findings for complaint control number 22-AS-20221018105523.

During the course of the investigation it was revealed that Staff 1 (S1) and Staff 2 (S2) were not associated to the facility Carver Senior Homes 1.

Deficiencies are being cited during today's Case Management visit.

An exit interview was conducted and a copy of this report, LIC809D, LIC811,LIC 421BG and appeal rights were provided. A CIVIL PENALTY IS ASSESSED.

SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/17/2022 03:32 PM - It Cannot Be Edited


Created By: Andrea Mendivil On 11/17/2022 at 02:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: CARVER SENIOR HOMES 1
FACILITY NUMBER: 306005756

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2022
Section Cited
CCR
87411(g)(2)

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(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall;
(2) request a transfer of a criminal record clearance as specified in Section 87355(c)
This requirement is not met as evidenced by:
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Licensee provided CCLD with LIC 9182, LIC 508 and copy of CA Drivers License to LPA to associate S1 and S2
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Staff 1 (S1) and Staff 2 (S2) are not associated to the facility. This poses an immediate health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022


LIC809 (FAS) - (06/04)
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