198204950-3-26-2022-11-AS-MVAO-CCZ3RJ-20220329182849

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 03/23/2022
Date Signed: 03/26/2022 12:02:43 PM

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
07/23/2021 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210723154309

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: 170	DATE:	03/23/2022
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	GINGER ENRIQUEZ		TIME COMPLETED:	03:59 PM

ALLEGATION(S):

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Facility is not communicating with the responsible party.
Facility not responding to changes in resident health
.Facility is not assisting the resident with hygiene needs.

INVESTIGATION FINDINGS:

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On 03/23/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced complaint visit at this facility, LPA was greeted by Maggie Ornelas administrator. LPA explained the purpose of today's inspection visit and to collect information.

The investigation consisted of the following: A review of the roster for residents and staff. A review of resident #1 (R1's) service records. Interview conducted with staff #1-#5 (S1-S5), residents #1-#6 (R1-R6), and witness #1-#6 (W1-W6) A tour of the entire facility was inspected on 07/30/21 and 03/23/22.

Evaluation Report continues on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210723154309

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: 03/23/2022

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Facility is not communicating with the responsible party.
Facility not responding to changes in resident health.

It is alleged the staff failed to communicate with the responsible party whenever there is a change in condition with resident #1 (R1) and failed to respond to changes in resident health. The complainant did not have specific dates or times regarding these allegations occurred. The Department interviewed witness #1 (W1) who stated she had difficulties getting a hold of any staff for updates with (R1’s) condition. (W1) claims she made several attempts to reach the administrator by phone or email during the COVID pandemic and communication went unnoticed. An interview with staff #1- #2 (S1-S2) both dispute these allegations and state they were both on the phone notifying the responsible representative for any changes in the resident's health condition. Furthermore, written documentation would have been created and submitted to Community Care Licensing (CCLD). The Department verified no Unusual Incident Reports about (R1) have been received. The complainant stated there were several in-person visits made at the facility and it was understaffed in Arbor Hall and only found one (1) staff on duty. The complainant was unable to provide dates to support this accusation. The Department examined the staffing schedule for July 2021, and it indicated that Arbor Hall had (18) staff scheduled for the month. It showed a minimum of (4) caregivers with two (2) med-techs on schedule. Interviews with residents #2- #6 (R2-R6) and family members witnesses #2-#6 (W2-W6) claimed the staff provided adequate communication with family representatives and were complimentary of staff during the pandemic. The communications with the administrator or staff were never a concern or an issue according to witnesses. The Department reviewed (R1’s) service records and tried to interview (R1) who was present on the 07/30/21 visit and was unable to hold a conversation as a result of her health condition. Based on the information collected, there is no evidence to support the allegations mentioned above.

Evaluation Report continues on LIC 9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210723154309

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: 03/23/2022

NARRATIVE

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Allegation: Facility is not assisting the resident with hygiene needs.

The details on this complaint allege the facility failed to assist resident #1 (R1) with hygiene needs. The complainant claims(R1’s) personal hygiene is neglected by staff. An interview with witness #1 (W1) expressed (R1) was provided poor services and neglected. (W1) claims she had demonstrative evidence to support neglect did occur with (R1’s) but failed to the evidence.

The Department examined (R1’s) physician’s report and it exhibited that (R1) requires assistance with personal hygiene, grooming, and medication care. Interviews with staff #1-#5 (S1-S5) reported that (R1) was assisted daily and was never neglected with care as required by her physician. The Department examined the facility’s Shower Logs and the Resident Incontinent 2-Hour Check logs and uncovered the services were performed and the records were accurate and maintained in order. Interviews with residents #2-#6 (R2-R6) reported the staff is responsive with their care. Moreover, witnesses #2-#6 (W2-W6) reported the staff provided satisfactory services and is complimentary of them. The Department observed (R1) did not appear unkempt or presented an unpleasant odor due to inadequate hygiene care on an in-person visit on 07/30/21. The Department tried to interview (R1) and was not able to hold a conversation as a result of her health condition. Based on the information collected, there is no evidence to support the allegation mentioned above.

Based on information gathered, an inspection of the facility, observation, analysis of (R1's) service records, and interviews conducted, the Department found no evidence to support the allegations listed on this complaint report.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted with Ginger Enriquez and a copy of the report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2022

LIC9099 (FAS) - (06/04)

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