Carver Senior Homes 1

Allegation investigated: Staff physically abused resident

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez for the purpose of delivering findings. LPA met with Administrator (AD) Van Pao and explained the purpose of the inspection. It is alleged Staff 1 (S1) and Staff 2 (S2) physically abused Resident 1 (R1). Interviews were conducted with five facility residents, including R1, and S1 and S2. During their interview, R1 stated only S1, and not S2 had been physically abusive towards them, however, stated the abuse had occurred in the past. On February 22, 2023, the Department received complaint #22-AS-20230222151633 alleging facility staff sexually abused R1 and on May 16, 2025, the complaint was determined to be unsubstantiated. During their interview, Resident 2 (R2) denied staff being physically abusive to either them or R1 and stated, staff loves R1 and "they love me too!" (Cont. LIC9099-C) Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 23, 2026 · control 22-AS-20251223121237

Allegation investigated: Facility staff handled resident roughly

On January 21, 2026, Licensing Program Analyst (LPA) Brandon Lopez made an unannounced visit to the facility to deliver the complaint findings. LPA was greeted and granted entry into the facility by staff after explaining the purpose for the visit. Administrator (AD) Van Pao was notified via telephone and later arrived to assist with the inspection. During the course of the investigation, the Department interviewed residents, interviewed staff, reviewed and obtained pertinent documents for this complaint. Regarding the allegation, facility staff handled resident roughly, the following has been concluded: It was alleged that facility staff handled Resident # 1 (R1) roughly. LPA attempted to speak with R1 regarding this allegation, however, R1 refused to be interviewed. LPA conducted five staff interviews. Five out of the five staff interviewed denied the allegation and stated that staff have never handled R1 in a rough manner. Staff interviewed also stated that R1 has made similar allegthe state’s words, verbatim · CDSS document, Jan 21, 2026 · control 22-AS-20230424101734

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff are not meeting resident's dietary needs. Staff are not providing adequate food service to resident in care. Staff physically abused residents in care. Staff verbally abuse residents in care.

An unannounced Complaint Investigation was conducted on this day by Licensing Program Analyst (LPA) Claudia Gutierrez. LPA met with Licensee Carmen Nicolas and explained the purpose of the inspection. Regarding the allegations, Staff are not meeting resident's dietary needs and Staff are not providing adequate food service to resident in care, the following was revealed: It is alleged Staff 1 (S1) is controlling Resident 1’s (R1’s) food intake at R1’s responsible party, Witness 1’s (W1’s) request. During the course of the investigation, interviews were conducted with R1, S1, W1, four additional facility residents, and two additional staff. During their interview, R1 stated their dietary needs are not being met, as they are hungry all the time. Per R1, they are not served with sufficient food at mealtimes and cannot snack in between meals because W1 is "cuckoo" and tells the staff not to give them any food. During their interview, W1 stated that due to R1’s medical diagnosis, R1 is unabthe state’s words, verbatim · CDSS document, Nov 13, 2025 · control 22-AS-20251105113209

Allegation investigated: Facility did not accord resident privacy. Resident was admitted without required admission documentation.

Licensing Program Analysts (LPA) Kerry Hiratsuka and Cheyenne Ratajczak, conducted this unannounced complaint visit to deliver the results of the allegations above. The Department conducted an investigation into allegations above. The allegation was made in January 2023. A review of the resident's file today showed the file is complete and all required paperwork upon admission were signed prior to the resident moving in. Interviews conducted showed one resident had a camera with the responsible party's consent and the responsible party was the only one who had access to the camera feed. Otherwise, no one else has cameras in their rooms. A tour of the rooms showed no cameras in resident rooms. Based on information above, the department concluded that the allegations are Unfounded. A finding that an allegation is unfounded means that the allegation is false, could not have happened, and/or is without a reasonable basis. nothe state’s words, verbatim · CDSS document, Jul 12, 2025 · control 22-AS-20230109131855

Allegation investigated: Staff sexually abused a resident.

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 Unsubstantiatedthe state’s words, verbatim · CDSS document, May 16, 2025 · control 22-AS-20230222151633

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.