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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005756
Report Date: 11/17/2022
Date Signed: 11/17/2022 03:15:20 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
10/18/2022 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221018105523
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: 5DATE:
11/17/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Isaiah Tashiro TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Facility does not have a certified Administrator.
Alterations to the building were made without obtaining a permit.
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannouced visit to deliver findings on the above allegations. LPA Mendivil discussed the following findings with Isaish Tashiro.

It was alleged the facility does not have a certified Administrator and there were alterations to the building without obtaining a permit. LPA reviewed documents, guardian and interviewed staff along with residents. The Department has investigated the complaint and has determined as follows.

Based on interviews Licensee VIRGILIO DE GUZMAN passed away on 06/27/2022, Staff 1 (S1) was then brought on to act as administrator from 06/28/2022 to current. Staff 2 (S2) was then hired to replace S1 as a permanent administrator. Based on review of the guardian website neither S1 or S2 are associated to the facility. CONT on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
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 6
Control Number 22-AS-20221018105523
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
VISIT DATE: 11/17/2022
NARRATIVE
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Based on interviews with local ombudsman modifications were made to the facility in May or June of 2022. Documentation provided by the facility indicates City of Placentia Fire and Life Safety visited the facility on 09/21/2022 and advised facility they needed to obtain permits for building modifications. S1 reported that they changed the windows on bedroom

Based on the preponderance of evidence the allegations that Facility does not have a certified Administrator and Alterations to the building were made without obtaining a permit are SUBSTANTIATED, meaning the complaint allegation as valid and that a violation has occurred.

Based on above findings deficiencies are being cited per California Code of Regulations Title 22 Divison 6 Chapter 8.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 22-AS-20221018105523
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: 11/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/23/2022
Section Cited
CCR
87305(a)
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87305 Alterations to Existing Building or New Facilities
(a) Prior to construction or alterations, all facilities shall obtain a building permit. This regulation was not met as evidence by: Facility built a double door in resident 1 (R1) room without a permit. This poses a potential safety risk to persons in care.
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Licensee applied for permit on 10/18/2022. Licensee to show proof of permit when it is obtained by the city and forward proof to LPA by POC due date.
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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: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
10/18/2022 and conducted by Evaluator Andrea Mendivil
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20221018105523

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: DATE:
11/17/2022
UNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Isaiah Tashiro- Administrator TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Residents are being served two meals a day.
INVESTIGATION FINDINGS:
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On this day Licensing Program Analyst (LPA) Andrea Mendivil made an unannouced visit to deliver findings on the above allegations. LPA Mendivil discussed the following findings with Isaiah Tashiro.

It is alleged that the facility serves residents two meals a day. LPA reviewed facility sample meals, observed the fridge food supply and interviewed staff along with residents. The Department has investigated the complaint and has determined as follows:

Based on interviews with 4 out of 6 residents all reported they are served 3 meals a day as well as snacks. 2 of the 6 residents were unable to be qualified due to not being oriented to time and space. Interviews with 4 out of 4 staff stated they offer 3 meals a day to all residents, some residents do not accept all 3 meals offered. All staff indicated they will provide residents with options for each meal.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 22-AS-20221018105523
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
VISIT DATE: 11/17/2022
NARRATIVE
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Based on interviews with residents and staff the allegation that the facility serves two meals a day is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. This agency has investigated this complaint and an exit interview was conducted
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 22-AS-20221018105523
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: 11/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2022
Section Cited
CCR
87405(a)
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Administrator - Qualifications and Duties. All facilities shall have a qualified and currently certified administrator...The administrator...to permit adequate attention to the management and administration of the facility as specified in this section...documentation
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Licensee to associate administrator to the facility by POC due date and forward proof to LPA
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This is not met as evidence by there is no Administrator associated to the facility after the passing of the licensee/administrator. This poses an immediate health and safety risk to persons in care.
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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: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 6