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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005756
Report Date: 05/16/2025
Date Signed: 05/16/2025 07:43:53 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
02/22/2023 and conducted by Evaluator Donna Gurriere
COMPLAINT CONTROL NUMBER: 22-AS-20230222151633
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:
05/16/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:CARMEN NICOLASTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff sexually abused a resident.
INVESTIGATION FINDINGS:
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On 05/16/25, Donna Gurriere, Licensing Program Analyst (LPA) contacted the facility to advise of the final findings regarding a complaint that was received on 02/22/23. LPA Gurriere spoke with Carmen Nicolas, Licensee and explained the purpose of the contact.

Staff sexually abused a resident.

During the interview process, a staff person and the resident (Resident 1) were interviewed. In addition, documents were reviewed and obtained to include the Physicians Report, Emergency Information, Appraisal, Medication Administration Records (MARs) and the Resident Facility Roster.

continued
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025
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 2
Control Number 22-AS-20230222151633
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: CARVER SENIOR HOMES 1
FACILITY NUMBER: 306005756
VISIT DATE: 05/16/2025
NARRATIVE
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During the investigation, of a complaint received on 02/22/23, the resident (Resident 1) alleged that two persons from the facility sexually abused him. Staff were interviewed and denied the allegation. The resident was interviewed; however, made inconsistent statements and questionable credibility of the allegation. No actionable evidence was gathered during the investigation.

Although the above allegation mentioned may have happened, or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred, and the above findings are Unsubstantiated.

Licensee/administrator was advised a copy of this report will be sent via certified mail. Two copies of the report will be sent. The Licensee is to sign and return one copy to the Orange County Regional Office.
SUPERVISOR'S NAME: Lauren CrockerTELEPHONE: (916) 261-4966
LICENSING EVALUATOR NAME: Donna GurriereTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2