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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 03/16/2022
Date Signed: 03/17/2022 06:08:27 AM

Unsubstantiated


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
03/10/2022 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220310100030
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:
03/16/2022
UNANNOUNCEDTIME BEGAN:
08:44 AM
MET WITH:Ginger Enriquez TIME COMPLETED:
03:17 PM
ALLEGATION(S):
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Staff did not prevent residents from engaging in physical altercation.
INVESTIGATION FINDINGS:
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On 03/15/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced complaint visit at this facility, LPA was greeted Ginger Enriquez administrator. LPA explained the purpose of today's inspection visit and to gather 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-#10 (R1-R10), and witness #1 (W1) A tour of the entire facility was conducted.

An exit interview was conducted with Ginger Enriquez, and a copy of this report is provided.
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: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
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 2
Control Number 11-AS-20220310100030
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: 03/16/2022
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:
Allegation: Staff did not prevent residents from engaging in a physical altercation.
It is alleged that a physical altercation between residents occurred on 03/09/22 and that no staff got involved to prevent it. The complainant states resident #1 (R1) and an unknown female resident got into a fight and hit one another. An unknown staff was present and did nothing to prevent it from happening. An interview with (R1) confirmed she instigated the fight by grabbing the female's forearm. However, (R1) is uncertain of the name of the female resident or staff who witness the incident. (R1) unable to describe any witnesses involved and claims there were many residents at the time. (R1) states she did not suffer from injuries only a mild pain when hit with an uppercut that landed across her right side of the face. (R1) later recanted stated the female's name who is non-ambulatory and uses a wheelchair for mobility. (R1) claims the other resident was blocking the entrance of the dining area during lunchtime. (R1) reports she notified medical technician staff #2 (S2) who later informed administrator staff #1(S1). (R1) added no medical assistance was required and was not seen by a physician. Interviews conducted with residents #2-#10 (R2-R10) revealed no one is able to verify this incident and no one observed any act of aggression on residents. (R2-R10) stated staff are responsive and will not allow for any residents to engage in any type of behavior. Interviews with staff #1-#2 (S1-S2) both mentioned in (R1's) narrative; disputes having any knowledge of the incident. There is no evidence of the incident recorded in daily progress notes nor an unusual incident report submitted to Community Care Licensing (CCLD). Additional interviews with staff #3-#5 (S3-S5) claim they did not witness or have knowledge of such incident ever occurred. (S3) claims if any of the kitchen staff observed this type of behavior, one will immediately report it. (S1) claims no video camera footage was captured. The Department observed (R1) no bruising, bump, or wounds on the face that would indicate some type of impact had occurred from the alleged incident.

Based on information gathered, an inspection of the facility, observation, analysis of (R-1)'s service records, and interviews conducted, the Department found no evidence to support the allegation listed on this complaint report.

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: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2