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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204950
Report Date: 09/06/2022
Date Signed: 09/06/2022 03:30:16 PM


Document Has Been Signed on 09/06/2022 03:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY 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: 172DATE:
09/06/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:33 PM
MET WITH:Ginger Enriquez TIME COMPLETED:
03:31 PM
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On 09/06/22 Licensing Program Analyst, LPA Ernand Dabuet conducted a Case Management visit to follow up on the death reported for resident#1 (R1). LPA was greeted by Ginger Enriquez and explained the purpose of the visit was to gather information surrounding the death of (R1).

The regional office received a copy of the death report from the facility and reported the death of (R1) on 09/02/22. The death report stated on 08/26/22 (R1) was declared dead at a park in Pomona, California reported by Investigator K. Anderson of the Pomona Police Department. The facility staff had last seen (R1) on 08/26/22 after breakfast at the facility and left the premises on his own for his daily outing. The facility is unable to obtain detail information as it is under investigation. The time, place and cause of death is unknown at this time.

The following documents were requested:

ID and Emergency Information,
Admission Agreement
Physical Health Intake Assessment,
Physician Report for Community Care Facilities,
Pre-Admission Assessment.
Medications (MAR)
Food menu

An exit interview was conducted with Ginger Enriquez and a hard copy was provided.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2022
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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