198204950-7-26-2021-11-AS-JHAD-C672S5-20210823173833

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 07/23/2021
Date Signed: 07/26/2021 10:36:31 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
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/18/2021 and conducted by Evaluator Ulysses Coronel

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210618162058

FACILITY NAME:	CARSON SENIOR ASSISTED LIVING		FACILITY NUMBER:	198204950
ADMINISTRATOR:	SHOLOM GOLDMAN		FACILITY TYPE:	740
ADDRESS:	345 EAST CARSON STREET		TELEPHONE:	(310) 830-4010
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY:	230	CENSUS: 174	DATE:	07/23/2021
		UNANNOUNCED	TIME BEGAN:	01:14 PM
MET WITH:	Ginger Enriquez		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident suffered falls while in care.
Staff did not properly administer insulin to resident.
Staff not feeding resident.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Ulysses Coronel initiated a complaint investigation for the allegations listed above. LPA met with Ginger Enriquez the facility administrator and the purpose of the visit was explained.

The investigation consisted of the following: On 06/24/2021 LPA interviewed witnesses W1 and W2. On 06/24/2021 LPA interviewed the administrator, 3 staff and 2 clients. LPA inspected the facility and requested resident and staff records. On 06/25/2021 LPA conducted Regional Office records review. On 07/16/2021 LPA conducted resident records review. On 07/22/2021 LPA interviewed 10 out of 174 residents and 1 med tech staff. On 07/23/2021 LPA reviewed facility records and interviewed administrator.

The investigation Revealed the following: Regarding the allegation: “Resident suffered falls while in care.” On 07/23/2021 A review of the facility's internal incident reports indicate that on 06/16/2021 at 7am R1 did not suffer a fall but was found on their bed unresponsive by staff S7.

Report continues please see LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021

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 11-AS-20210618162058

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
MONTEREY PARK, CA 91754

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
	VISIT DATE: 07/23/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On 06/24/2021 when asked if they had a fall at facility on 06/16/2021 R1 stated "I don't know, I do not remember." On 07/23/2021 the administrator stated that "R1 did not fall on 06/16/2021 but was found unresponsive in their bed." On 07/23/2021 staff S7 stated that "I saw R1 in bed unresponsive on 06/16/2021 and I reported it to med tech S3. Regarding the allegation: “Resident suffered falls while in care.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation:” Staff did not properly administer insulin to resident.” On 06/18/2021 the department received information that R1 was given insulin on an empty stomach. On 06/24/2021 when asked if they ate dinner the night before the incident R1 stated “yes". During today’s visit the administrator stated that R1 administers own insulin injections and staff only provides assistance. Regarding the allegation” Staff did not properly administer insulin to resident.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Regarding the allegation: “Staff not feeding resident.” On 06/24/2021 witness W2 stated "R1 does not like the food at the facility and refuses meals often " Staff S3 stated “R1 refuses meals." Staff S6 stated "We have a list of residents who goes out on dialysis. Staff delivers meals to their rooms, for example if they go in the morning and are out all day, we deliver lunch and dinner to them." R1 stated “When I do not like the food or when I have no appetite. My family also brings me food." On 07/22/2021 10 out of 10 residents interviewed denied not being given food by staff during meals. Regarding the allegation: “Staff not feeding resident.” Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted. A copy of this report was provided to Ginger Enriquez, the administrator.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses Coronel	TELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2