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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 07/24/2020
Date Signed: 07/27/2020 06:47:36 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/18/2020 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20200518170811
FACILITY NAME:CARSON SENIOR ASSISTED LIVINGFACILITY NUMBER:
198204950
ADMINISTRATOR:SHOLOM GOLDMANFACILITY TYPE:
740
ADDRESS:345 EAST CARSON STREETTELEPHONE:
(310) 830-4010
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:230CENSUS: 147DATE:
07/24/2020
UNANNOUNCEDTIME BEGAN:
01:49 PM
MET WITH:Ginger Enriquez TIME COMPLETED:
03:48 PM
ALLEGATION(S):
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The facility accepted the resident without proper authorization from an authorized representative.
The facility failed to give resident medication as prescribed
Staff failed to transport residents to appointments.
Staff failed to provide adequate supervision resulting in resident eloping.
The facility in disrepair.
The resident was injured while in care.
INVESTIGATION FINDINGS:
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On 07/24/20 Licensing Program Analyst, LPA/Ernand Dabuet initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s subsequent complaint investigation was conducted telephonically with Ginger Enriquez/Administrator at this facility.

The investigation consisted of the following: Interviews conducted with staff, residents, and witnesses. Copies were obtained of current staff/resident roster, (R1's) pre-placement appraisal, physician’s report, emergency contact information, needs and service plan, medication records, staff schedule, photographs, and a plant inspection of the facility.

Evaluation Report continues on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2020
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 4
Control Number 11-AS-20200518170811
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: CARSON SENIOR ASSISTED LIVING
FACILITY NUMBER: 198204950
VISIT DATE: 07/24/2020
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Investigation Revealed the following;

Allegation: “The facility accepted the resident without proper authorization from an authorized representative.”

It is alleged Resident #1 (R1) was admitted without proper authorization from an authorized representative. Interviews were conducted with residents (R2-R10) staff (S1-S7), and a review of (R1’s) service records revealed there is no evidence to back this allegation. The Department reviewed (R1’s) Admissions Agreement and it revealed (RI) self admitted himself to this facility. There was no reference that (R1) had a Power of Attorney as the claimant had claimed. An interview with (S1) reports the admission process with (RI) was not a short-term process as (R1) and companion (W1) contacted (S1) for at least a three month period. (S1) states that (R1) had done the research and did multiple inquiries prior to his admission. An interview with residents (R2-R10) staff (S1-S7) indicated that all residents go through a pre-screen admissions process which includes a physical assessment. No resident is allowed without going through this course. Based on the (R1’s) physical assessment and physician’s report dated 02/21/18, (R1’s) physical and mental condition qualified (R1) to reside in the assisted living and not memory care unit as the claimant had required. The claimant did not provide evidence that she was on record as the Power of Attorney when (R1) was admitted in July 2018. The claimant did not provide medical records for review. Based on the interviews and service records inspected, there is no evidence to support the allegation mentioned above.

Allegation: “The facility failed to give resident medication as prescribed.”

It is alleged that (R1) had missed his medications as staff failed to refill medications. Interviews were conducted with residents (R2-R10) staff (S1-S7), and a review of (R1’s) Medication Administration Record (MAR) from July through November 2018 revealed there is no evidence to corroborate this allegation. An interview with (S3 and S5) both Med-Techs responsible for residents’ medications and was present during (R1’s) residence at this facility. Both staff claimed that (R1) did not miss his medications due to unfilled prescriptions. (S3) states that she recalled (R1’s) companion (W1) was very much involved with his medications. (W1) would call to make sure that his meds were being administered to him daily. A review of (R1’s) (MAR) revealed that each medication was given daily and that no gaps between July through November 2018. Interviews with residents (R2-R10) were present during (R1's) residency indicated that they received their medications daily. Based on the interviews and service records inspected, there is no evidence to support the allegation mentioned above.

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20200518170811
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: CARSON SENIOR ASSISTED LIVING
FACILITY NUMBER: 198204950
VISIT DATE: 07/24/2020
NARRATIVE
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Allegation: “Staff failed to transport residents to appointments.”

It is alleged the facility failed to transport (RI) to appointments. Interviews were conducted with residents (R2-R10) staff (S1-S7), and there is no evidence to back this allegation. (S2) reports the facility in 2018 the appointments were not entered on a computer. All the hard copies of log records from 2018 are no longer available. Interviews with residents (R2-R10) staff (S1-S7) indicated that transportation is provided. (S1-S7) reported transportation is provided to residents for medical and dental appointments which is a basic service implemented by the facility and outlined in the Residential Admissions Agreement. The residents present during 2018 were interviewed and reports they did not miss any appointments due to facility failing to provide transportation. The claimant declined to produce any written proof of this charge. Based on the interviews, there is no evidence to support the allegation mentioned above.

Allegation: “Staff failed to provide adequate supervision resulting in resident eloping.”

It is alleged the facility failed to provide adequate supervision which resulted in (R1) to elope. The claimant states that (R1) eloped for several hours and was found on the freeway. The claimant states it was in November 2018 when this incident happened, and that law enforcement was involved with a written report. The Department contacted Carson Sheriff’s Station and was informed there is no record found. Interviews with (S1-S7) present during 2018, indicated (R1) is independent and would go out during the day and would return to the facility with no problems. There was no staff interviewed was able to confirm (R1) eloped. There is no record of an incident report to CCLD to support this allegation. Interviews with residents (R2-R10) were present in 2018 could not account for knowing of any residents who eloped and were escorted by law enforcement. The Department was provided with a Staffing Schedule for November 2018 and it indicated that (18) staff were scheduled for (4) shifts throughout the entire month. According to interviews conducted, a review of the staffing schedule, and no proof of a police report, there is no evidence to back this allegation.



Allegation: “The facility in disrepair “
“The resident was injured while in care.”

It is alleged the resident was in a disrepair room and was injured while in care. According to claimant reports (R1) was injured on his head the first week he was admitted. (R1) tripped on a loose carpet in his room.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20200518170811
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754
FACILITY NAME: CARSON SENIOR ASSISTED LIVING
FACILITY NUMBER: 198204950
VISIT DATE: 07/24/2020
NARRATIVE
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The claimant also claimed that the air conditioning unit was not working during the hot summer months in 2018. (S2) states she was not aware if the air conditioning unit was not operating as the resident never made the facility aware of its condition. (S1-S2) confirmed that (R1’s) room was never in disrepair and along with residents (R2-R10) and staff (S3-S7). They confirmed that each room is remodeled and repaired once it is vacated, which means that (R1's) room was serviced prior to his admittance. (S1-S2) reports that air conditioning in a room is an option and not all rooms come equipped with an air conditioning unit. If there is one in a room; it was either purchased, brought, or existed from the previous resident. It is the resident’s responsibility for the repairs. This service is not included in the Residential Admission Agreement as part of basic services. (S2) did confirm that the facility will provide a fan for a room if requested by the resident at no extra cost. The facility is equipped with central heating and no central air. The Department conducted a plant inspection and observed the (R1's) former room to be maintained, clean and air conditioning no longer in place.
(S2) reports that (R1) during his stay from July through November 2018 had no medical injuries or incidents. Interviews with staff (S3-S7) confirmed they were not aware (R1's) head injury. The claimant reports that she had dialog with (S2) about the incidents that had occurred but neglected to provide the Department with the evidence. (S2) denies ever speaking with the claimant about any incidents regarding (R1). Based on interviews and observation, there is no evidence to confirm these allegations are valid.

Based on the lack of supportive evidence, no statement from (R1), and information gathered from the facility, the Department did not find sufficient grounds to support the allegations: “The facility accepted the resident without proper authorization from an authorized representative.”, “The facility failed to give resident medication as prescribed,”, “Staff failed to transport residents to appointments.”, “Staff failed to provide adequate supervision resulting in resident eloping.”, “The facility in disrepair “ and “The resident was injured while in care.”

Although the allegations may have happened or are valid, there is not enough preponderance of evidence to verify the alleged allegations are valid did or did not occur. Therefore, the allegations are "unsubstantiated.”

A telephonic exit interview was conducted with Ginger Enriquez, and a hard copy was provided via email for signature.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 4