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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005756
Report Date: 02/19/2025
Date Signed: 02/19/2025 11:40:05 AM

Document Has Been Signed on 02/19/2025 11:40 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/
DIRECTOR:		ISAIAH TASHIROFACILITY TYPE:
740
ADDRESS:16202 CAIRO CIRCLETELEPHONE:
(714) 572-8821
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
02/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:20 AM
MET WITH:Katherine EspinaTIME VISIT/
INSPECTION COMPLETED:
11:55 AM
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 Staff Katherine Espina and the purpose of the inspection was discussed.

During the inspection, LPA and Staff Espina 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. LPA observed all resident beds had linens and blankets. LPA observed all windows were screened. The backyard 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 117.1 degrees Fahrenheit. 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. Toxic chemicals, cleaning solutions, and disinfectants were observed to be inaccessible to residents. Medication was observed to be centrally stored in a locked cabinet. LPA reviewed four resident files and three staff files. Staff files did not contain any documentation for for hands-on shadowing medication training and annual training completed did not include eight hours of dementia care training, and four hours specific to postural supports, restricted health conditions, and hospice care; a Deficiency was cited on today’s date. LPA interviewed three residents and three staff.

Based on the observations made during today’s inspection, two 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 and appeal rights was left at the facility.
Armando J LuceroTELEPHONE: (714) 703-2840
Claudia GutierrezTELEPHONE: 714-703-2840
DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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 02/19/2025 11:40 AM - 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: 02/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
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 record review, the licensee did not comply with the section cited above in three of three staff files which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 03/19/2025
Plan of Correction
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Staff Espina stated staff training will be completed and proof provided to LPA via email by POC date.
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 in one of one staff files which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 03/19/2025
Plan of Correction
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Staff Espina stated 10 hours of initial training consisting of 6 hours of hands-on shadowing training will be documented and a copy provided 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.
Armando J LuceroTELEPHONE: (714) 703-2840
Claudia GutierrezTELEPHONE: 714-703-2840

DATE: 02/19/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/19/2025

LIC809 (FAS) - (06/04)
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