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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005639
Report Date: 11/17/2022
Date Signed: 11/17/2022 02:15:17 PM

Substantiated


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
10/14/2022 and conducted by Evaluator Jerome Haley
COMPLAINT CONTROL NUMBER: 22-AS-20221014145836
FACILITY NAME:CARVER SENIOR HOMES 2FACILITY NUMBER:
306005639
ADMINISTRATOR:GUZMAN VIRGILIO DEFACILITY TYPE:
740
ADDRESS:17581 SHANE WAYTELEPHONE:
(714) 401-2689
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:6CENSUS: 5DATE:
11/17/2022
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Rebecca De La Alas & Arturo GuerreroTIME COMPLETED:
02:05 PM
ALLEGATION(S):
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Staff did not provide a skilled professional to properly care for resident’s ileostomy.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit to deliver the findings on the complaint allegation above. LPA identified himself and discussed the purpose of the visit with staff. Staff called Licensee/Administrator (AD) Carmen Nicolas via telephone and LPA Haley explained to her the reason for today's visit.
The investigation into the allegation “Staff did not provide a skilled professional to properly care for resident’s ileostomy” revealed the following:
During the initial visit October 20, 2022 LPA Haley interviewed the licensee, staff, and residents. During the interview process with multiple individuals, LPA Haley received information that confirms the allegation above is true.
Based on the evidence gathered, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. Violations are being cited per California Code of Regulations Title 22, Division 6.
An exit interview was conducted, a copy of this report, LIC809D, and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 22-AS-20221014145836
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: CARVER SENIOR HOMES 2
FACILITY NUMBER: 306005639
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/17/2022
Section Cited
CCR
87621(a)(2)
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Colostomy/Ileostomy
(a) Except as specified in Section 87611(a), the licensee shall be permitted to accept or retain a resident who has a colostomy or ileostomy under the following circumstances: (2) If assistance in care of the ostomy is provided by an appropriately skilled professional.
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Licensee/Administrator agrees to have a skilled professional train all staff members on proper Colostomy/Ileostomy care before admitting a resident who needs ostomy care.
Licensee/Administrator agrees to provide this training to the department before admitting a new resident who needs ostomy care.
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This requirement is not being met as evidenced by: During interviews with the licensee/Administrator LPA Haley was told they have not been trained by a skilled professional to provide care for the residents ileostomy.
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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: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
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
LIC9099 (FAS) - (06/04)
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