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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005639
Report Date: 12/23/2024
Date Signed: 12/23/2024 11:50:33 AM

Document Has Been Signed on 12/23/2024 11:50 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:CARVER SENIOR HOMES 2FACILITY NUMBER:
306005639
ADMINISTRATOR/
DIRECTOR:
GUZMAN VIRGILIO DEFACILITY TYPE:
740
ADDRESS:17581 SHANE WAYTELEPHONE:
(714) 401-2689
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
12/23/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:00 AM
MET WITH:Administrator- Isaiah TashiroTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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This is an amended report because the previous report is missing signatures.

On December 23, 2024, at 8:00 am, Licensing Program Analysts (LPAs) Edward Kim and Eboni Bentley conducted a continuation visit for a required 1-year annual visit that was started on December 17, 2024. LPAs Kim and Bentley were greeted and gained entry to the facility by Caregiver (CG) Janet Novero. LPA Kim met with Administrator (AD) Isaiah Tashiro and explained the purpose of the visit.

LPA Kim conducted a record review of medication and the medication administration record, first aid kit, video teleconferencing device, smoke detector and carbon monoxide detector check, staff interviews, and resident interviews.

No deficiencies were cited at the time of the visit.

An exit interview was conducted and a copy of this report was provided to Administrator Isaiah Tashiro.

Lourdes MontoyaTELEPHONE: (916) 956-7332
Edward KimTELEPHONE: (714) 293-1237
DATE: 12/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/23/2024
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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