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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005756
Report Date: 03/20/2025
Date Signed: 03/20/2025 04:04:54 PM

Document Has Been Signed on 03/20/2025 04:04 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/
DIRECTOR:
ISAIAH TASHIROFACILITY TYPE:
740
ADDRESS:16202 CAIRO CIRCLETELEPHONE:
(714) 572-8821
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
03/20/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:11 PM
MET WITH:Carmen NicholasTIME VISIT/
INSPECTION COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Claudia Gutierrez made an unannounced Plan of Correction (POC) inspection. LPA was greeted and granted entry by Licensee Carmen Nicholas and the purpose of the inspection was discussed.

LPA is following-up on deficiencies cited on February 19, 2025, during annual inspection. Deficiency 1569.625(b)(2) was cited as annual staff training records for three staff did not include eight hours of dementia care training, and four hours specific to postural supports, restricted health conditions, and hospice care. During today’s visit, LPA reviewed staff training records for three of three staff and observed staff files to include required annual staff training.

Deficiency 1569.69(a)(2) was cited as staff file for employee of the facility who assists residents with the self-administration did not contain any documentation for hands-on shadowing medication training. During today’s visit, LPA reviewed staff training records for one of one staff and observed staff file to include hands-on shadowing medication training.

Both POCs have been met and deficiencies previously cited will be cleared.

Based on today’s observations, no 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.

Armando J LuceroTELEPHONE: (714) 703-2840
Claudia GutierrezTELEPHONE: 714-703-2840
DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
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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