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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005756
Report Date: 05/29/2024
Date Signed: 05/29/2024 03:25:54 PM


Document Has Been Signed on 05/29/2024 03:25 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 1FACILITY NUMBER:
306005756
ADMINISTRATOR:ISAIAH TASHIROFACILITY TYPE:
740
ADDRESS:16202 CAIRO CIRCLETELEPHONE:
(714) 572-8821
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY:6CENSUS: 5DATE:
05/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Carmen NicholasTIME COMPLETED:
03:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced visit for the purpose of conducting a Required/Annual Inspection. LPA was greeted and granted entry by Licensee Carmen Nicholas and explained the purpose of the inspection.

During the inspection LPA and Licensee conducted a tour of the inside and outside of the facility, common areas, resident rooms, kitchen, garage and observed the following:

This is a one-story home with five resident bedrooms, two bathrooms, and attached two-car garage. All resident bedrooms had the required furnishings, however, in bedroom of Resident 1 (R1), LPA observed and obtained a picture of a 32 ounce plastic urinal container containing R1’s urine, being stored without a lid in R1's room; a Deficiency was cited on today’s date. LPA observed all resident beds had linens and blankets. The back yard has a shaded sitting area. LPA observed residents resting in their respective bedrooms. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested at 114.8 degrees Fahrenheit.

LPA observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted. LPA observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Gas stove, microwave, washer, and dryer were all inspected and observed to be operable. Sharps were observed locked in a kitchen drawer. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to residents. Medication cabinet was observed to be locked.

Administrator (AD) Isaiah Tashiro arrived at 11:00 a.m. to assist with the inspection. LPA reviewed five resident files and three staff files. Three out of five resident files did not have a completed appraisal dated in the last twelve months; a Deficiency was cited on today’s date. (Cont. LIC809-C)

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
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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Document Has Been Signed on 05/29/2024 03:25 PM - It Cannot Be Edited

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 1
FACILITY NUMBER: 306005756

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87470(a)(2)(D)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products.  These activities shall be completed, at a minimum, as follows:  (D) Facility items that cannot be disinfected shall be discarded immediately in an appropriate waste receptacle with a tight-fitting cover or otherwise made inaccessible to human contact or transmission. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and resident interview, the licensee did not comply with the section cited above as a resident is urinating into a urinal plastic container and the urine filled container is stored without a lid in the resident's room, which poses an immediate health and personal rights risk to persons in care.
POC Due Date: 05/30/2024
Plan of Correction
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AD stated urinal plastic container would be disposed of by staff immediately after use and will no longer be stored in resident's bedroom. AD stated infection control training would be completed for staff and proof submitted to LPA via email by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/29/2024 03:25 PM - It Cannot Be Edited

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 1
FACILITY NUMBER: 306005756

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(a)(2)(A)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products.  These activities shall be completed, at a minimum, as follows:  (A) Surfaces such as floors, chairs, toilets, sinks, counters and tabletops shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary.  These surfaces shall also be disinfected when these surfaces are contaminated and visibly soiled with blood or body fluids or other potentially infectious material. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in hallway and resident's bedroom floors, which poses a potential health and safety risk to persons in care.
POC Due Date: 06/05/2024
Plan of Correction
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AD stated a staff cleaning log would be maintained to ensure daily disinfecting of floors. AD stated they will submit proof to LPA via email by POC date.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff file review, the licensee did not comply with the section cited above as facility staff have not completed eight hours of dementia care training, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, which poses a potential health and safety risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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AD stated remaining required annual staff training would begin to be completed immediately. AD stated they will submit proof to LPA via email by POC date.
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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/29/2024 03:25 PM - It Cannot Be Edited

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 1
FACILITY NUMBER: 306005756

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as staff's 6 hours of hands-on shadowing training is not being documented, which poses a potential health and safety risk to persons in care.
POC Due Date: 05/30/2024
Plan of Correction
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AD stated staff's 6 hours of hands-on shadowing training will be documented and proof will be submitted to LPA via email.
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of five resident files, which poses a potential health and safety risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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AD stated resident appraisals would be completed and pre-admission appraisals completed for all future residents. AD stated proof will be submitted to LPA via email by POC date.
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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 05/29/2024 03:25 PM - It Cannot Be Edited

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 1
FACILITY NUMBER: 306005756

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of five resident files, which poses a potential health and safety risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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AD stated resident appraisals will be completed and proof will be submitted to LPA via email by POC date.
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of five resident files, which poses a potential health and safety risk to persons in care.
POC Due Date: 06/28/2024
Plan of Correction
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AD stated all admission agreements would be signed and dated for currently residents and signed and dated within seven days for any new resident. AD stated proof will be submitted to LPA via email by POC date.
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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6


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 1
FACILITY NUMBER: 306005756
VISIT DATE: 05/29/2024
NARRATIVE
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Staff files did not contain any documentation for initial 6 hours of hands-on required medication shadowing training. AD stated training was conducted upon hire but was not originally documented. Staff file review indicated 20 hours of annual training has been completed, however, did not contain eight hours of dementia care training, and four hours of which shall be specific to postural supports, restricted health, and hospice; two additional Deficiencies were cited on today’s date. LPA interviewed three residents and two staff.

Based on the observations made during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Claudia GutierrezTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
LIC809 (FAS) - (06/04)
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