306005756-7-12-2025-22-AS-LMUZ-DK52BM-20250731171522

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005756
Report Date: 07/12/2025
Date Signed: 07/12/2025 12:40:41 PM

Unfounded

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
01/09/2023 and conducted by Evaluator Kerry Hiratsuka

COMPLAINT CONTROL NUMBER: 22-AS-20230109131855

FACILITY NAME:	CARVER SENIOR HOMES 1		FACILITY NUMBER:	306005756
ADMINISTRATOR:	DE GUZMAN, VIRGILIO		FACILITY TYPE:	740
ADDRESS:	16202 CAIRO CIRCLE		TELEPHONE:	(714) 572-8821
CITY:	PLACENTIA	STATE: CA	ZIP CODE:	92870
CAPACITY:	6	CENSUS: 6	DATE:	07/12/2025
		UNANNOUNCED	TIME BEGAN:	12:09 PM
MET WITH:	Carmen Nicolas		TIME COMPLETED:	12:48 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility did not accord resident privacy.
Resident was admitted without required admission documentation.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analysts (LPA) Kerry Hiratsuka and Cheyenne Ratajczak, conducted this unannounced complaint visit to deliver the results of the allegations above.
The Department conducted an investigation into allegations above. The allegation was made in January 2023.
A review of the resident's file today showed the file is complete and all required paperwork upon admission were signed prior to the resident moving in.
Interviews conducted showed one resident had a camera with the responsible party's consent and the responsible party was the only one who had access to the camera feed. Otherwise, no one else has cameras in their rooms. A tour of the rooms showed no cameras in resident rooms.
Based on information above, the department concluded that the allegations are Unfounded. A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis.
no deficiencies cited

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Troy Ordonez
LICENSING EVALUATOR NAME: Kerry Hiratsuka
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2025

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 1