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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005639
Report Date: 11/14/2022
Date Signed: 11/14/2022 02:53:51 PM


Document Has Been Signed on 11/14/2022 02:53 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 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:
11/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:58 PM
MET WITH:Arturo Guerrero, Rebecca De LA AlasTIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Jessica Cho arrived at Carver Senior Homes 2 to conduct an unannounced Required 1 Year Inspection with an emphasis on Infection Control. At 2:00pm, LPA Cho was greeted and granted entry by Caregiver Rebecca De Las Alas. Also present was Caregiver Arturo Guerrero. LPA spoke to Administrator (Admin) Karmian Calangi over the telephone and authorized Caregiver Guerrero to participate in the exit interview and sign the evaluation report. LPA completed the Coronavirus 2019 (COVID-19) screening procedure upon entry. There are no active COVID-19 cases as of today. LPA observed a check-in station with a thermometer. Facility does not document temperatures of visitors on the sign-in sheet. LPA observed the required COVID-19 precautionary signs posted throughout the facility. The Complaint Poster (PUB475) was observed in the size of 11"x14" which did not meet the size requirement. PUB475 was purchased during the visit. The facility is licensed for six non-ambulatory residents and has a hospice waiver for four. There are currently five residents living in the facility of which one is receiving hospice care.

At 2:10pm, LPA Cho conducted a tour of the physical plant with Caregiver Rebecca De Las Alas. There are a total of five resident bedrooms and two resident bathrooms. There is a private staff bedroom and bathroom. LPA checked the resident bedrooms. The resident bedrooms had the required furnishings. The resident bathrooms were checked. Grab bars were secure, the toilets worked properly, the showers were free of mold/mildew, and slip mats were in place. Resident bath towels and personal hygiene supplies were adequately stocked including hand soaps and paper towels. LPA observed hand washing signs in the bathrooms. The hot water temperature in the resident bathrooms measured at 113.3 degrees Fahrenheit in Bathroom #1 and 117.7 degrees Fahrenheit in Bathroom #2. Perishable and non-perishable food supplies were checked and adequately stocked at the time of the visit. The fire extinguisher was mounted, fully charged, and serviced on 07/28/2022. Smoke/carbon monoxide detectors and auditory devices were tested and operational. Medications, toxins, and sharps were locked and inaccessible to the residents. LPA Cho toured the outside grounds. No body of water was present.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/14/2022
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There was shading and sufficient seating for residents. The exit gate was self-closing and self-latching. Walkways around the facility were clear of hazards, and LPA observed sufficient supply of emergency food/water and PPEs.

Based on the observations made during today's visit, no deficiency is cited in this review as per Title 22 Division 6 of the California Code of Regulations. Advisory Notes (LIC9102s) were issued during the visit.

An exit interview was conducted with Caregiver Arturo Guerrero, and a copy of this report was provided.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 334-2064
LICENSING EVALUATOR NAME: Jessica ChoTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2022
LIC809 (FAS) - (06/04)
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