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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 502701290
Report Date: 04/08/2024
Date Signed: 04/08/2024 12:21:57 PM

Document Has Been Signed on 04/08/2024 12:21 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:CARVER CARE RESIDENTIALFACILITY NUMBER:
502701290
ADMINISTRATOR/
DIRECTOR:		CALLA, PATRICIAFACILITY TYPE:
735
ADDRESS:1009 CARVER ROADTELEPHONE:
(209) 204-5157
CITY:MODESTOSTATE: CAZIP CODE:
95350
CAPACITY: 70CENSUS: 41DATE:
04/08/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Administrator Ashley GudinoTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jason Lund arrived unannounced to do a case management visit. LPA Lund met with Administrator Ashley Gudino and explained the reason for the visit. Census: 41

LPA Jason Lund received an Unusual Incident/Injury Report (LIC 624) on 4/3/2024 from the facility stating that client (C1) eloped from facility on 4/2/2024. C1’s LIC 602 dated 2/23/2024 states that C1 cannot leave the facility unassisted.

Per California Code of Regulations, Title 22, the following deficiencies, and immediate civil penalty have been issued.

Exit interview conducted and report provided. Appeals rights printed.
SUPERVISORS NAME: Lisa Rios
LICENSING EVALUATOR NAME: Jason Lund
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 04/08/2024 12:21 PM - It Cannot Be Edited


Created By: Jason Lund On 04/08/2024 at 12:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: CARVER CARE RESIDENTIAL
FACILITY NUMBER: 502701290

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/09/2024
Section Cited
CCR
80078(a)

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80078 (a) Responsibility for Providing Care and Supervision (a) The licensee shall provide care and supervision as necessary to meet the client's needs.
This requirement is not met as evidenced by:
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The facility will look of over the regulation and have training and email a copy of the training to LPA Lund
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Based on interviews conducted and records reviewed, the facility did not insure client C1 was appropriately supervised, resulting in C1’s AWOL which posed an immediate health, safety, and personal rights risk to the clients 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:Lisa Rios
LICENSING EVALUATOR NAME:Jason Lund
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024


LIC809 (FAS) - (06/04)
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