198204950-6-2-2022-11-AS-UCOL-CFSVRS-20220627164024

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 06/02/2022
Date Signed: 06/02/2022 10:46:13 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
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/25/2022 and conducted by Evaluator Susan Campos

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220525162747

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: 169	DATE:	06/02/2022
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Ginger Enriquez		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility ceiling is in disrepair.

INVESTIGATION FINDINGS:

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On 6/2/22 at 9:45 am., Licensing Program Analyst (LPA)/ Susan Campos, initiated a 10-day complaint investigation visit for the allegation listed above. LPA was allowed entry into the facility by Assistant Administrator Ginger Enriquez. LPA explained to Ms. Enriquez the purpose of the visit. The investigation consisted of the following: LPA conducted interviews on 6/2/22 with (6) staff members and (17) residents. In addition, on 6/2/22, LPA and Ms. Enriquez conducted an inspection, for health and safety of the facilities’ physical plant, and food supply. LPA also reviewed the following documents provided by Carson Senior Assisted Living Assistant Administrator Ginger Enriquez: LIC 500-staff roster, client roster, maintenance staff schedule, Maintenance Incident Reports May 2022, House Rules, Repair Request Form, and Procedure for Maintenance Repair Requests.

Report continued on LIC 9099C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Susan Campos	TELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

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-20220525162747

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
MONTEREY PARK, CA 91754

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
	VISIT DATE: 06/02/2022

NARRATIVE

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Allegation: Facility ceiling is in disrepair

The investigation revealed, per LPA interviews, with (6) staff members, (17) residents from the Carson Senior Assisted Living facility, and also review of facility documents, that the facility memory care dining room ceiling is in disrepair. S1 informed the LPA, that the facility has a maintenance and housekeeping staff that addresses any repairs needed in the facility. S1 also informed the LPA, that S3 addresses work order requests submitted by staff and residents for repairs to the facility. In addition, S1 is not aware of a facility ceiling in disrepair, and has not received reports from S3, staff or residents that the facility ceiling is in disrepair. S2 informed the LPA that S3 had reported to S2, that there was ceiling damage in the Memory Care Dining Room. In addition, S2 informed the LPA that the ceiling damage was in the process of repair, and would be completed immediately, S2 will send LPA pictures once repair has been completed. LPA interviewed S3, and was informed by S3, that S3 is in the process of repairing ceiling damage in the Memory Care Dining room, and had notified S2, two weeks ago of the ceiling damage, and also S3 was in the process of obtaining a contractor to work on the repair. S1 provided LPA with Work Order and Incident Report, both dated 5/19/22, regarding ceiling damage. In addition, S1, S2 and S3 informed the LPA that all facility curtains are replaced by the maintenance staff once there is a report that they are damaged. The LPA also interviewed (6) facility staff personnel, and 4 of the 6 staff personnel interviewed, informed the LPA that they are not aware of the facility ceiling in disrepair. In addition, 6 facility staff personnel interviewed, 6 of 6 staff members informed the LPA that they are not aware or have been informed that there are damaged curtains in the facility. In addition, the LPA interviewed (17) residents, and 15 of 17 residents interviewed, informed the LPA, that the facility does not have damaged ceilings. Also, the LPA interviewed 17 residents, and 15 of 17 residents interviewed, informed the LPA that the facility staff assist them with their care needs, and also, 15 of 17 residents interviewed, informed the LPA that staff are available to them when needed. Two of 17 residents interviewed, by the LPA did not answer LPA questions. LPA and S1 inspected the facility interior and perimeter grounds, and did not observe ripped or damaged curtains.

On 6/2/22, at 10:30 am, LPA and S1 observed Memory Care Dining room ceiling, missing plaster, and partial open ceiling with wire meshing exposed.

Based on information gathered, the LPA did find sufficient evidence to support allegation " Facility ceiling is in disrepair ”

Report continued on LIC 9099C

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Susan Campos	TELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220525162747

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
MONTEREY PARK, CA 91754

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
	VISIT DATE: 06/02/2022

NARRATIVE

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Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Exit interview was conducted with Ginger Enriquez, Assistant Administrator and a hard copy of the LIC 9099 and LIC 9099D was provided.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Susan Campos	TELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 11-AS-20220525162747

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
MONTEREY PARK, CA 91754

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/02/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/10/2022 Section Cited HSC 80087(a)	1 2 3 4 5 6 7	80087(a)Buildings and Grounds(a)The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator will fax to LPA picture of repaired Memory Care Dining Rm ceiling, and also a signed self-certification statement that Administrator read and understands Regulation 80087 Building Grounds. POC Due Date is 6/10/22 LPA Fax Number (323)981-1781
	8 9 10 11 12 13 14	Based on interviews, and record review, the licensee failed to ensure that the facility was in good repair. On 6/2/22, at 10:30am, LPA and S1 observed Memory Care Dining Room ceiling missing plaster, partial open ceiling, and exposed mesh wire, which posed a potential health risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Ulysses Coronel	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Susan Campos	TELEPHONE: (323) 629-7445
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

LIC9099 (FAS) - (06/04)

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