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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005756
Report Date: 02/14/2022
Date Signed: 02/14/2022 11:14:24 AM


Document Has Been Signed on 02/14/2022 11:14 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:CARVER SENIOR HOMES 1FACILITY NUMBER:
306005756
ADMINISTRATOR:DE GUZMAN, VIRGILIOFACILITY TYPE:
740
ADDRESS:16202 CAIRO CIRCLETELEPHONE:
(714) 572-8821
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY:6CENSUS: 6DATE:
02/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:06 AM
MET WITH: Administrator Virgilio De GuzmanTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Albert Marin made an unannounced required annual inspection in this facility. LPA met with Administrator (AD) Virgilio De Guzman and stated the purpose of this visit.

The facility is a single level structure and licensed for six non-ambulatory of which one maybe bedridden and with hospice waiver for four. For this visit there were two residents under hospice care.

About 10:06 AM, LPA Marin was granted entry after completing the Coronavirus 2019 (COVID 19) screening procedure. For this visit, there were six residents in care and three staff members on the floor. LPA toured the interior and exterior portions of the facility. There were four private and one shared resident’s rooms. Rooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke, carbon monoxide and auditory exit alarms were tested to be operational. Bathrooms were observed to be in good repair; and provided with handrails and nonskid - floor mats. Hot water was measured at 110 degrees Fahrenheit. Facility met the minimum two-day perishable and seven-day non-perishable food stock requirements. Medications, cleaning supplies and sharp items were inaccessible to residents in care. Fire extinguisher was mounted and charged. For the exterior portion, facility had patio furniture in good repair, and grounds were free of tripping hazards. Side exit door was self-latching and self-closing. LPA Marin reviewed the COVID 19 mitigation plan of the facility.

For this visit, the facility was observed to be in substantial compliance with Title 22 Division 6 of the California Code of Regulations.

LPA Marin conducted an exit interview with AD Virgilio De Guzman; and copy of this report was left in the facility.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Albert MarinTELEPHONE: (714) 309-7843
LICENSING EVALUATOR SIGNATURE:
DATE: 02/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/14/2022
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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