198204950-7-20-2022-11-AS-EMAZ-CHW434-20220902184409

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 07/20/2022
Date Signed: 07/20/2022 05:54:35 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
07/11/2022 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20220711140344

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: 168	DATE:	07/20/2022
		UNANNOUNCED	TIME BEGAN:	09:13 AM
MET WITH:	Gabby Eusebio & Julie Villanueva		TIME COMPLETED:	03:57 PM

ALLEGATION(S):

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Resident sustained an unexplained injury while in care.
Staff did not assist the resident with obtaining medical care.

INVESTIGATION FINDINGS:

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On 07/20/22, Licensing Program Analysts (LPAs) Ernand Dabuet conducted an unannounced complaint visit at this facility, LPA was greeted by medical technicians Gabby Eusebio and Julie Villanueva. Villanueva contacted administrator Ginger Enriquez by telephone and explained the purpose of today's inspection visit.

The investigation consisted of the following: LPA obtained copies of the roster for residents and staff. Interviews conducted with Resident #1-#5 (R1-R5), staff #1-#5 (S1-S5), and witnesses #1-#5 (W1-W5). A reviewed of (R1's) service records and other pertinent documents pertinent to the allegations on this complaint. A tour of the facility was performed.

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: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

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-20220711140344

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
	VISIT DATE: 07/20/2022

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegations: Resident sustained an unexplained injury while in care.
Staff did not assist the resident with obtaining medical care.

The details of this complaint allege resident #1 (R1) sustained an unexplained injury while in care and that staff failed to assist the resident with obtaining medical care. The complainant states she observed (R1) with a swollen arm/wrist on 07/06/22 during an outing with family members. The complainant alleges the unexplained injury occurred while (R1) is under care at this facility. The department interviewed (R1) who claims the staff provides adequate care services. (R1) asserts he has no concerns for his health or safety while being cared for by staff. (R1) does not recall how he injured his left wrist. In an interview with witness #1 (W1), the power of attorney for (R1) states these allegations are false. (W1) reports she was with (R1) during the family outing on 07/06/22 and did not observe (R1's) left wrist to have been severely swollen. (W1) argues due to (R1's) medical condition, a flare-up and swelling in the joints may occur. (W1) states this condition might have been caused by (R1's) food consumption for lunch or dinner during his outing. (R1) is on a special diet. (W1) declares the swelling did not happen while at the facility, but while he was out with family members. Interviews with staff #1-5 (S1-S5) reported that they did not observe any swelling or injuries on (R1's) wrist before his departure with family members. Interviews with residents #2-#5 (R2-R5) and witnesses #2-#5 (W2-W5) did not know any residents with unexplained injuries. (R2-R5) and (W2-W5) expressed the staff provides adequate care and supervision.

The complainant asserts staff did not assist (R1) with medical care and did not make medical records for (R1) accessible for review. The Department interviewed (R1) who does not recall receiving medical attention for his wrist on 07/06/22. However, medical records from Kaiser Permanente Hospital revealed that (R1) received immediate medical attention on 07/06/22 and that the exam and imaging suggest that there are no serious injuries. Interviews with (S1-S5) verified that (R1's) power of attorney (W1) was notified immediately of the incident when (R1) returned from the family outing and was taken to the emergency for medical observation. Incidents reports and email communications verified the authorizing representative was notified on 07/06/22. Interviews with (R2-R5) and (W2-W5) expressed that they had no issues with the staff seeking medical attention for residents promptly.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20220711140344

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
	VISIT DATE: 07/20/2022

NARRATIVE

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EVALUATION REPORT CONTINUES

(S2) claims that medical records were not made accessible to the complainant and that only the release of resident medical information is made available to the authorized representative for (R1). A review of service records indicates that (W1) power of attorney is the only authorized representative for (R1) on file.

The complainant added concerns for (R1's) hygiene and claims that during an in-person visit on 07/07/22, she noticed (R1) seemed unkempt and did not appear to be groomed. During the investigation, the Department observed (R1) in a presentable appearance. (R1) appeared well groomed and did not exude an unpleasant odor. A review of (R1's) daily monitoring of ADLs and progress notes indicates that (R1) is being cared for on an hourly basis.

According to (W1) power of attorney for (R1) claims this is all a misunderstanding. (W1) describes that there is an ongoing litigation with family members over (R1's) guardianship.

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 allegations mentioned in this complaint.

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.

No deficiencies were cited during this visit.

An exit interview 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: 07/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2022

LIC9099 (FAS) - (06/04)

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