306005756-8-20-2021-22-AS-SSAS-CFLV2F-20220621160302

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306005756
Report Date: 08/20/2021
Date Signed: 08/20/2021 05:21:20 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
08/11/2021 and conducted by Evaluator Michelle Reed

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210811135850

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:	08/20/2021
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Virgilio DeGuzman		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident's have locks on their bedroom doorknobs from the outside

INVESTIGATION FINDINGS:

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

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021

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 3

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
08/11/2021 and conducted by Evaluator Michelle Reed

COMPLAINT CONTROL NUMBER: 22-AS-20210811135850

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:	08/20/2021
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Virgilio De Guzman		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee is not following the admission agreement for residents
Residents' leave facility unassisted

INVESTIGATION FINDINGS:

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

Licensing Program Analyst Michelle Reed arrived at the facility to discuss the complaint allegations. Upon arrival, LPA met with Carmen Nicholas. Staff Nielgar Buton and Ransy Laxamana were also present. Administrator Virgilio De Guzman arrived a short time later.
Resident's were interviewed and files were reviewed. The Licensee's Admission Agreement(House Rules) states that drugs or any illegal substances are prohibited. R1 has a prescription for medical marijuana. R1 wants to store the marijuana in R1's room, however, R1's cannot store his/her own medications. Mr. DeGuzman will followup with R1's Physician. Physician reports of residents' were reveiwed. 6 of 6 reports disclosed that the resident could not leave the facility unassisted. Licensee Virgilio De Guzman is reminded that he and staff must assist/supervise residents who wish to leave the facility.
Based upon interviews and a review of records, the allegations above are unsubstantiated, meaning that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred. An exit interview was conducted and a copy of this report was given to Virgilio DeGuzman.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021

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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 22-AS-20210811135850

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 1	FACILITY NUMBER: 306005756
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/20/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/21/2021 Section Cited CCR 87468.1(a)(6)	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities-Residents in all residential care facilities for the elderly shall have the following personal right: To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator Virgilio De Guzman removed the the doorknobs at the time of visit and stated he will replace them with a doorknob that does not have a lock. He went to Home Depot during LPA's visit and installed the new knobs.
	8 9 10 11 12 13 14	Residents' in Room #2, #4 and #5 had locks on the outside of their doorknobs. This poses an immediate health and safety and personal rights risk to resident's in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle Reed	TELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021

LIC9099 (FAS) - (06/04)

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