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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204950
Report Date: 04/18/2022
Date Signed: 04/19/2022 05:51:44 AM


Document Has Been Signed on 04/19/2022 05:51 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
198204950
ADMINISTRATOR:SHOLOM GOLDMANFACILITY TYPE:
740
ADDRESS:345 EAST CARSON STREETTELEPHONE:
(310) 830-4010
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:230CENSUS: 170DATE:
04/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:GINGER ERIQUEZ TIME COMPLETED:
03:25 PM
NARRATIVE
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On 04/18/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. LPA met with administrator Ginger Enriquez. LPA explained the purpose of today’s visit. The facility is licensed for (230) non-ambulatory with (10) who may be bedridden. The facility is licensed for (10) residents on Hospice along with dementia residents in Arbor Hall.

The facility is a two-story structure located in a commercial neighborhood. It consists of the following: (35) resident bedrooms in Arbor Unit and (99) resident bedrooms in Assisted Living. Each room has a bathroom in the unit, activity room, dining area, kitchen, and outside patio area.

LPA toured the physical plant. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the client's personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational.

LPA observed the facility to be sanitary and appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable. A review of Fire Drills was observed to be maintained in order and accurate. The last fire drill was performed on 03/22/22, and a Disaster Drill was conducted on 12/27/21. Several working landline phones are available on-site. A record review of (8) residents' service files was conducted.

Evaluation Report continues on LIC 809C
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/18/2022
NARRATIVE
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DEFICIENCY:
During the inspection, LPA observed Room 219 without hot water. The faucet was not working and did not
provide hot water. LPA inspected the following rooms: 265, 269, 246, 209, 159, 147, 41, 36, and the men's public restroom on the first floor. In Arbor Hall rooms 5, 23, and 28 were inspected. Faucets used by residents for personal care such as shaving and grooming produced hot water temperature controls at 105 degrees F (41 degrees C) and not more than 120 degrees F (49 degrees C)

INFECTION CONTROL:
LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed staff wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. A review of staff and resident temperature logs and COVID vaccinations were conducted.

Deficiencies were cited during this inspection visit.

An exit interview was conducted and a copy of this report was provided to Ginger Enriquez.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 04/19/2022 05:51 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation), the licensee did not comply with the section cited above in [1] out of [13] [(rooms)[identify] did not provide hot water. This violation poses immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 04/19/2022
Plan of Correction
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Licensee will adhere to Title 22 Section 8703 (e) and ensure that water temperature is maintained to automatically regulate hot water not less than 105 degrees F and not more than 120 degrees F. The licensee will repair the water faucet in room 219 so that it will regulate hot water per regulations.
Type A
Section Cited
CCR
87303(e)(1)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (1) All community care facilities where water for human consumption is from a private source shall:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation), the licensee did not comply with the section cited above in [1] out of [13) [(rooms) room 219] did not provide hot water. This violation poses immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 04/19/2022
Plan of Correction
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Licensee will adhere to Title 22 Section 8703 (e)(1) and ensure that water temperature is maintained to automatically regulate hot water not less than 105 degrees F and not more than 120 degrees F. The licensee will repair the water faucet in room 219 so that it will regulate hot water per regulations.

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: 04/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 04/19/2022 05:51 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) the licensee did not comply with the section cited above in [1] out of [13] [(rooms) failed to produce hot water for personal care use. The violation poses immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 04/19/2022
Plan of Correction
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Licensee will adhere to Title 22 Section 8703 (e)(2) and ensure that water temperature is maintained to automatically regulate hot water not less than 105 degrees F and not more than 120 degrees F. The licensee will repair the water faucet in room 219 so that it will regulate hot water per regulations.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4

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: 04/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4