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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 11/10/2021
Date Signed: 11/11/2021 06:30:39 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
10/25/2021 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20211025133621
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: 169DATE:
11/10/2021
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ginger Enriquez TIME COMPLETED:
03:31 PM
ALLEGATION(S):
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Resident is missing after eloping from the facility.
Staff are not providing adequate supervision.
INVESTIGATION FINDINGS:
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On 11/10/21 Licensing Program Analyst, (LPA) Ernand Dabuet initiated a subsequent complaint visit for the allegations listed above. LPA was greeted by administrator Ginger Enriquez and explained the purpose of the visit.

The investigation consisted of the following: An interview with the administrator, resident #2 (R2), staff 2-#3 (S2-S3). A review of service records, incident reports, photographs, and other pertinent documents was reviewed. A tour of the facility on 11/02/21 and 11/10/21.

Evaluation Report continues on LIC 9099-C
Substantiated
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: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
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 4
Control Number 11-AS-20211025133621
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/20/2021
Section Cited
CCR
87705(b)(2)
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87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including:.(2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.
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Licensee agrees that a Plan of Correction will be submitted to CCLD by 11/20/21. Administrator agreed that Arbor Hall staff will be advised to be on "high alert" meaning being more vigilant in monitoring all access exit door and windows while a Plan of Correction is developed by POC date 11/20/21 to the licening office.
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This requirement was not met as evidence by:
Based on LPA observations, interviews conducted and record reviews, the Licensee failed to ensure to address R1's history of wandering behavior and went missing, while unsupervised by facility staff. This violaiton poses an immediate health and safety risk to residents in care.
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Type B
11/20/2021
Section Cited
CCR
87466
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87466 Observation of the Resident
State regulations require the licensee to ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.
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Licensee shall have a written plan to ensure that in addition to the resident's needs and services plan a specific plan is drafted for each resident's change in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. The plan must be submitted by POC date 11/202/21 to the liceninsg office.
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Based on LPA observations, interviews conducted and record reviews, the Licensee was aware of of R1's history of wandering behavior failed to ensure proper supervision was in in place. This violation poses a potential health and safety risk to residents 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: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20211025133621
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: 11/10/2021
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Resident is missing after eloping from the facility.
Staff is not providing adequate supervision.

The detail on allegations states, resident #1 (R1) is a resident at Carson Senior Assisted Living who eloped from the facility and now is missing. According to the complainant (R1) had wandered off from the facility multiple times and the staff is not providing adequate supervision. According to administrator Ginger Enriquez, on 10/23/21, ((R1) had dismantled the window locks in room #21. (R1) was able to take apart one of the slider windows of its track and left through by pushing out the window screen at 10:30 pm. Enriquez reported that the staff searched for (R1) throughout the entire interior and exterior sections of the facility and that no traces of (R1) was found. Enriquez claims the facility immediately contacted the Carson Sheriff's Department and filed a missing person report. Enriquez asserts the incident had occurred when the afternoon shift was transitioning to the night shift. The afternoon shift had three (3) staff working from 2:30 pm - 10:30 pm and two (2) staff working 10:30 pm - 6:30 am for the graveyard shift when the incident occurred. Enriquez admitted that this was not the first time (R1) had fled the facility and that (R1) had disappeared on 8/28/21 and was found by law enforcement within a few hours. At that time, (R1) entered through the same room #21 and managed to get out the same process through the slider window by breaking the window. According to Enriquez, the staff in Arbor Hall were doing hourly checks with all the residents at 11 pm when caregivers discovered (R1) was missing. The Department reviewed (R1's) service records and it states in (R1's) Physician's Report is not able to leave the facility unassisted and may get lost or not maintain safety.

The Department interviewed resident #2 (R2) who was an actual witness when the incident happened and confirmed details on how (R1) was able to escape from the facility through her room window. (R2) reported that no staff was available during the time it occurred to supervise. An interview with staff #2-#3 (S2-S3) recalls the incident and verifies the time and date when it happened. (S2) reports the incident that occurred during shift changes. (S2) states at around 10:30 pm she was doing her normal routine round checks and that (R1) was not found inside her room #27. During her inspection of the entire floor for (R1), (S2) observed the window slider was taken off its track and the locks were broken. (S2) immediately notified management and law enforcement. (S2-S3) both acknowledge that (R1) had a history to wander.
Evaluation Report continues on LIC 9099-C
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20211025133621
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: 11/10/2021
NARRATIVE
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During the interview with (S2), when asked do you have sufficient staffing during the graveyard shift, (S2) responded the staff would welcome any added assistance. Based on the information gathered, there’s sufficient evidence to corroborate the allegations.

Based on the Department's observation and interviews, records reviews, and photographs conducted, the preponderance of evidence standard has been met, therefore the allegations of "Resident is missing after eloping from the facility", and "Staff is not providing adequate supervision" are found to be: Substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099-D.

An exit interview was conducted with Ginger Enriquez. The Rights were discussed and a copy of Appeals Procedures for Licensees was provided, as well as a copy of this report to the Administrator.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4