<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 04/04/2022
Date Signed: 04/04/2022 08:35:19 PM

Substantiated


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
03/09/2022 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220309075425
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: 166DATE:
04/04/2022
UNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:GINGER ENRIQUEZ TIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident sustained injuries while in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 04/04/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit at this facility, LPA was greeted by Ginger Enriquez administrator. LPA explained the purpose of today's inspection visit is to gather information and deliver findings.

The investigation consisted of the following: A review of the roster for residents and staff. A review of resident #1 (R1's) service records. Interviews with staff #1-#5 (S1-S5), residents #1-#6 (R1-R6), and witnesses #1-#6 (W1-W6) A tour of the entire facility was inspected on 03/09/22, 03/16/22 and 04/04/22.

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

DATE: 04/04/2022
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 5
Control Number 11-AS-20220309075425
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: 04/04/2022
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
INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Resident sustained injuries while in care.

The details on the complaint states resident #1 (R1) sustained injuries while in care. The complainant claims (R1) lives at this facility and has sustained bruises on his body while in care. The most recent was on 02/20/22 when (R1) had fallen off his wheelchair and sustained injuries. On 03/07/22 witness #2 (W2) came for a visit and confirmed (R1) had sustained injuries with bruises on the face. The Department reviewed (R1’s) service records and attempted an interview during the visit and was unable to hold a conversation as a result of his health condition. The Department observed (R1) with multiple bruises on his face. An interview with administrator staff #1 (S1) claims she was not made aware of the incident on 02/20/22. Otherwise, she would have taken action to have the resident examined at the hospital. Interviews with staff #3-#5 (S3-S5) all verified they did not notice (R1) any injuries on 02/19/22, however, they did observe him with bruises on his face 02/22/22. They did not inquire about (R1's) condition as there were no notes indicated on the daily progress notes for (R1). An interview with staff #2 (S2) who was present on the day of the incident claims (R1) was found on the floor in front of the television room and had signs of redness on his upper forehead. (S2) applied an ice pack and no other injuries were visible at the time. (S2) claims the incident happened at approximately 2:30 pm on 02/20/22 during a shift change. (S2) reported this incident to the responsible party and nurse practitioner witness #3 (W3) but failed to notify (S1). (W3) verified she was notified by (S2) of the incident and that (R1) had no major injuries and to monitor (R1’s) condition. When questioned, (W2) states that any impact on the head should be seen by a medical professional and may require further observation along with x-ray scans. (S1-S5) confirmed that no skilled medical professional examine (R1) from 02/20/22 through 03/20/22. (S2) verified that (R1) has a history of falls. The facility eventually had (R1) seen by his primary physician on 03/21/22. Based on information gathered, interviews, service records, and incident reports reviewed, there is sufficient evidence to corroborate the allegation mentioned above. The facility failed to ensure that (R1) was regularly observed for physical changes and that appropriate medical attention was provided promptly.



Based on the Department's observation and interviews, records and photographs reviewed, the preponderance of evidence standard has been met, therefore the allegation of "Resident sustained injuries while in care" is found to be: Substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099-D.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

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

DATE: 04/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20220309075425
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: 04/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/05/2022
Section Cited
CCR
87465(g)
1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis.

This requirement was not met as evidence by:
1
2
3
4
5
6
7
The licensee will submit a declaration on how staff will address injured residents shall be cared for in an emergency or resident care with primary care physician. LIcensee shall submit the protocol when dealing with emergency situaiton such as resident sustaining any injury by the POC date: 04/05/22.
8
9
10
11
12
13
14
Based on observation, interviews, and record reviews (R1) suffered head injuries during the fall. (R1) was not given immediate medical attention after a fall on 02/20/22. This violaiton poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
The emergency protocol shall state who is in charge of seeking medical care. Who to contact, who is in charge, and steps to be taken.
Type B
04/18/2022
Section Cited
CCR
87466
1
2
3
4
5
6
7
87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional... appropriate assistance is provided when such observation reveals unmet needs... licensee shall ensure that such changes are documented and brought to the attention of the resident's physician...
1
2
3
4
5
6
7
Licensee shall provide staff with training on observation of the residents. Licensee will provide copies of training materials and sign in sheet to CCL by POC 04/18/22 due date.
8
9
10
11
12
13
14
This requirement was not met as evidence by: Based on observation, interviews, and record reviews (R1) suffered head injuries during the fall. (S2-S5) observed physical changes in (R1) and failed to recognize to give immediate medical attention after a fall on 02/20/22. This violaiton poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
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: 04/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
03/09/2022 and conducted by Evaluator Ernand Dabuet
COMPLAINT CONTROL NUMBER: 11-AS-20220309075425

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: 166DATE:
04/04/2022
UNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:GINGER ENRIQUEZ TIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff failed to provide adequate transportation for resident.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 04/04/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit at this facility, LPA was greeted by Ginger Enriquez administrator. LPA explained the purpose of today's inspection visit and to collect information and deliver findings.

The investigation consisted of the following: A review of the roster for residents and staff. A review of resident #1 (R1's) service records. Interviews with staff #1-#7 (S1-S7), residents #1-#6 (R1-R6), and witnesses #1-#6 (W1-W6) A tour of the entire facility was inspected on 03/09/22, 03/16/22 and 04/04/22.

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

DATE: 04/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20220309075425
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: 04/04/2022
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
INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff failed to provide adequate transportation for resident.

It is alleged that the facility failed to provide transportation to resident #1 (R1) to medical appointments. The complainant states that in November 2021 the facility did not have transportation available for transport (R1) to his medical appointment. The Department reviewed (R1’s) service records and attempted to interview (R1) during the visit and was unable to hold a conversation as a result of his health condition. According to the Admission Agreement regarding transportation to medical and dental appointments, the office staff may assist residents to make medical/dental appointments. The transportation services are available to local medical offices within a 10-mile radius and no staff is available to stay with the resident unless the schedule permits. Interview with staff #1, #6 and #7 (S1, S6, and S7) claims that the family representatives are responsible for making the medical and dental appointments. The appointments have to be scheduled in advance to provide transportation services. The medical/dental appointments scheduled last minute or on the same day will not be a priority and it will be the responsibility of the resident’s representatives to make to make transportation arrangements unless there is a cancellation in the schedule. (S6-S7) verified that there was no request for (R1) in November according to the facility's medical/dental appointment calendar. An interview with staff #1 -#2 (S1-S2) verifies (R1) was being examined by an on-site nurse practitioner witness (W3) and did not have to leave the facility for medical appointments. This was arranged with (R1's) primary insurance and Assisted Living Waiver Program. However, this arrangement came to an end on 02/28/22. Effective 03/01/22, (R1) is now seen by his primary physician. Interviews with residents #1-#6 (R1-R6), and witnesses #1-#6 (W1-W6) did not have issues with medical/dental appointments nor transportation services.



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 allegation “Staff failed to provide adequate transportation for 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 with Ginger Enriquez and a copy of the report was provided.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

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

DATE: 04/04/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5