306005639-7-12-2023-22-AS-SSAS-CUJ9L5-20230808232719

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005639
Report Date: 07/12/2023
Date Signed: 07/12/2023 01:37:22 PM

Unsubstantiated

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
11/16/2022 and conducted by Evaluator Jerome Haley

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20221116151607

FACILITY NAME:	CARVER SENIOR HOMES 2		FACILITY NUMBER:	306005639
ADMINISTRATOR:	GUZMAN VIRGILIO DE		FACILITY TYPE:	740
ADDRESS:	17581 SHANE WAY		TELEPHONE:	(714) 401-2689
CITY:	YORBA LINDA	STATE: CA	ZIP CODE:	92886
CAPACITY:	6	CENSUS: 6	DATE:	07/12/2023
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Isaiah Tashiro - Administrator		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff handles resident roughly
Staff does not treat resident with respect

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jerome Haley made an unannounced follow up visit to gather additional information on the complaint allegations above. LPA Haley was greeted by staff and explained the reason for the visit upon entry. Staff contacted Administrator (AD) Isaiah Tashiro via telephone who arrived a short time later and was present for the remainder of the visit.

After conducting additional interviews and gathering more details on the complaint allegations, it was determined findings would be delivered at the end of the visit.

Regarding the investigation into the complaint allegations above, the initial visit was completed November 17, 2022, and 5 individuals were interviewed. A follow up visit was made July 12, 2023, and 7 additional individuals were interviewed. 2 interviews were conducted outside the facility via telephone for a total of 14 interviews conducted.
Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20221116151607

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
	VISIT DATE: 07/12/2023

NARRATIVE

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After conducting 14 interviews with individuals, the investigation revealed the following: 12 of 14 individuals interviewed were unable to corroborate the allegations as reported. Furthermore, 8 of the 12 individuals who were unable to corroborate the allegations, actually denied the allegations.

Based on the information gathered during the investigation through interviews, the Department is unable to ascertain if the allegations occurred as reported. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove or refute the alleged violations occurred; therefore, the allegations are deemed Unsubstantiated.

An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023

LIC9099 (FAS) - (06/04)

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