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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 11/04/2022
Date Signed: 11/04/2022 04:04:05 PM

Substantiated


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
02/09/2022 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220209105823
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: 173DATE:
11/04/2022
UNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:GINGER ENRIQUEZTIME COMPLETED:
04:22 PM
ALLEGATION(S):
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Resident fell and sustained a fracture.
Resident fell resulting in multiple injuries.
INVESTIGATION FINDINGS:
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On 11/04/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced visit to the facility and was greeted by Assistant Administrator staff #1 (S1). LPA explained the purpose of this visit is to deliver the findings on the allegations mentioned above.

The investigation consisted of the following: Licensing Program Analyst (LPA) Ernand Dabuet conducted a visit on 02/10/22 and 111/04/22. LPA investigated the allegations mentioned and interviewed with Assistant Administrator (S1). Staff rosters, SIR reports, physician's reports, appraisals/needs and services plans, and all medical records for resident #1 (R1) and other pertinent records associated with this complaint. The Department of Social Services investigator Phillipe Ryan Miles conducted a separate investigation that included a review of medical records and interviews with witnesses, facility staff, and medical services personnel.

Evaluation Report continues LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
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 10
Control Number 11-AS-20220209105823
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: 11/04/2022
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Resident fell and sustained a fracture


Resident fell resulting in multiple injuries.

Resident #1 (R1) admitted to the facility on 12/18/19. According to resident #1 (R1’s) Physicians Report, R1 was diagnosed on (05/13/19) with Dementia. While residing at this facility, (R1) had five unwitnessed falls on 07/13/22, 08/20/21, 11/21/21, 02/06/22, and 02/27/22.

On 08/20/21, (R1) was admitted to Harbor UCLA Medical Center and suffered from a forehead laceration and nasal fracture. On 02/06/22, (R1) suffered a laceration above the right eyebrow and had blood in the mouth. On 02/27/22, (R1) sustained a laceration to the left eyebrow.

On 03/02/22, IB Investigator interviewed Assistant Administrator (S1) regarding the allegations. (S1) stated that (R1) was admitted to the facility in 2019 and suffered from dementia. (S1) stated (R1) had three falls starting sometime in 2021: one in 2021, sometime in 2022, and on 02/27/22. (S1) stated each fall was “unwitnessed”. (S1) stated since the second fall in January 2022, two-hour rounds of monitoring to one-hour rounds of monitoring had been placed since January 2022. (S1) could not explain how (R1) fell the third fall that occurred on 02/27/22. It appears that (R1) was never evaluated by a professional physician regarding his mobility concerns according to (S1). In a statement from (S1), she said she was not present nor had witnessed any of (R1’s) falls in the facility. (S1) stated the residents who have dementia are “locked” in their room to contain them from wandering r or go into other’s resident’s rooms.

On 03/09/22, IB Investigator interviewed Administrator (S2). (S2) was unsure of (R1’s) diagnosis when admitted. (S2) described (R1) who is a mobile who liked to “walk and wander” throughout the facility with no supervision. According to (S2), (R1) had five “unwitnessed falls”. These falls occurred on: 07/13/20, 08/20/21, 11/12/21, early 02/22, and late 02/22. (S2) stated he was never a witness to any of these falls and was only notified. (S2) states that based on limited resources (insurance) available for (R1), the facility was not able to provide higher levels of care and supervision to (R1). (S2) unable to answer the question of why dementia residents are locked in rooms.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 10
Control Number 11-AS-20220209105823
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: 11/04/2022
NARRATIVE
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On 04/08/22, IB Investigator interviewed staff #3 (S3) med-tech supervisor, staff #4 (S4) Med-tech/caregiver, staff #5 (S5) caregiver, and staff #(S6) caregiver all in the Memory Care Unit. (S3) stated that (R1’s) behaviors changed with “a lot of redirecting” and (R1) required Activities of Daily Living (ADLs) and did not have assistance with any mobile devices. (S3 - S6) recalled (R1) had multiple falls all unwitnessed. (S3) reported, due to multiple falls, (R1) became a “fall risk”. (S3 - S6) mentioned the facility should have increased supervision or given one-on-one care, as that would have prevented the falls. (S3) stated dementia residents’ doors are locked when a resident is in their room. To prevent (R1) from wandering, (S5) claimed (R1's) door was locked and was restrained with a seatbelt. As for (S4 - S6), they reported that dementia residents should not be restricted to any device or locked in an indoor environment. (S4) stated it’s a fire hazard to restrain any residents to their wheelchairs.

A review of service records revealed no medical or needs and services assessment performed on (R1) since 2019. The facility did not have a Fall Prevention Plan for (R1). Multiple unwitnessed falls and injuries occurred because the facility did not provide the proper level of care and supervision. Investigator Ryan Miles and Investigator Heidy Bendana observed (R1) was restrained by a blanket tied and knotted around (R1’s) waist while in a wheelchair and was locked in a room on 03/03/22.



Based on the Department's observation, interviews, records reviewed and analysis, the preponderance of evidence standard has been met, therefore the allegation of “Resident fell and sustained a fracture” and “Resident fell resulting in multiple injuries” are found to be: Substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099-D.

At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.”
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 10
Control Number 11-AS-20220209105823
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: 11/04/2022
NARRATIVE
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During today’s visit a $500 Civil Penalty is assessed.
During today’s visit a $250 Civil Penalty is assessed.

An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to Administrator Ginger Enriquez.

ACTIONS:

· Immediate Civil Penalty

CITATIONS:

· Administrator Qualification and Duties

· Reporting Requirements

· Additional Personal Rights of Residents in Privately Operated Facilities

· Observation of Resident

· Care of Person with Dementia

· Postural Support

· Personal Right of Resident in All facilities

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 10
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
02/09/2022 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220209105823

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: 173DATE:
11/04/2022
UNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:GINGER ENRIQUEZTIME COMPLETED:
04:22 PM
ALLEGATION(S):
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Facility not allowing resident to receive visitors.
INVESTIGATION FINDINGS:
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On 11/04/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced visit to the facility and was greeted by Assistant Administrator staff #1 (S1). LPA explained the purpose of this visit is to deliver the findings on the allegation mentioned above.

The investigation consisted of the following: Licensing Program Analyst (LPA) Ernand Dabuet conducted a visit on 02/10/22 and 11/04/22. LPA investigated the allegations mentioned and interviewed with Assistant Administrator (S1) and (S3). Staff rosters, SIR reports, physician's reports, appraisals/needs and services plans, and all medical records for resident #1 (R1). A plant inspection of the facility conducted on 02/10/22 and 11/04/22.

Evaluation Report continues LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 10
Control Number 11-AS-20220209105823
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: 11/04/2022
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Facility not allowing resident to receive visitors.

It’s is alleged the staff is not allowing (R1) to have visitors. The complainant witness #1 (W1) reported a family member of (R1) was not allowed visitations. The complainant claims staff # 3 (S3) stated the facility stopped visitation two months ago due to COVID. The Department reached out to the family member witness #2 (W2) who was not available for comment.

(S1 and S3) claims due to COVID-19 and the measures set in place by Community Care Licensing, The Department of Public Health and Centers for Disease Control and Prevention mandated additional steps to ensure the health and safety of residents and staff from outside contact resulting in many cases suspending in-person face to face visitation, except when medically necessary to the care of the resident. Such as home health, hospice care, and end of life. (S1) states that the health and safety of residents and staff are of utmost importance, but also considers all the resident’s rights as well. According to (S1 and S3), (R1) was allowed visitors even from November 2021 through February 2022 when the facility had a surge of COVID activity throughout the facility after the holiday season. Visitors were allowed an in-person to visit through a window from a vacant room. (S3) claims room #17 was the designated room used for residents in Memory Care. All visitors had to sign in through the front and they could visit through the window and remain safe for all parties. The Department is unable to gather information related to this allegation due to (R1’s) medical condition. Interviews with residents #2-#10 (R2-R10) stated they had no issues related to visitations. (R2-R10) reported the facility was accommodating with visitations during the COVID pandemic.

Based on the Department’s observation, interviews, and a review of records that were conducted, the Department found there is no evidence to support the allegation mentioned above.

Based on information gathered, the Department did not find sufficient evidence to support the allegation: “Facility not allowing resident to receive visitors”.



Although the allegation may have happened or is valid, there is not enough preponderance of evidence to prove the alleged allegation is valid did or did not occur. Therefore, the allegation is "unsubstantiated.”

An exit interview conducted with Ginger Enriquez, and a hard copy was provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 10
Control Number 11-AS-20220209105823
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2022
Section Cited
CCR
87468.2(a)(8)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights... residents in privately operated residential care facilities for the elderly shall have...(8) To be free from neglect... involuntary seclusion... and verbal, mental, physical, or sexual abuse.
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Licensee/Administrator will adhere to Title 22 Sec. 87468.2 regarding personal right of residents and will certify written statement the regulations have been review and understood and will train staff on personal rights. Certification will be provided to CCLD by the POC due date: 11/07/22.
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This requirement is not met as evidenced by: Based on observations and interviews, the licensee did not comply with the section cited above. The facility confined, restricted, and isolated resident #1 in a locked room. This violation poses an immediate health, safety or personal rights risk to persons in care.
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*IMMEDIATE CIVIL PENALTY*
Type A
11/07/2022
Section Cited
CCR
87466
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87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes... and that appropriate assistance is provided... when such observation reveals unmet needs. When changes such as... deterioration of mental ability or a physical health condition... are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician...
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Licensee/Administrator will adhere to Title 22 Sec. 87466 regarding observation of the resident and will certify written statement the regulations have been review and understood and will train staff on regularly observation on residents conditions. Certification will be provided to CCLD by the POC due date: 11/07/22.
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This requirement is not met as evidenced by: Based on observations, record reviews and interviews, the faciltiy failed to address resident #1 required higher level of care and supervison. This violation poses an immediate health, safety or personal rights risk to persons in care.
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*REPEAT CIVIL PENALTY*
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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 10
Control Number 11-AS-20220209105823
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/18/2022
Section Cited
CCR
87211(a)(B)(D)
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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department... (B) Any serious injury... occurring while the resident is under facility supervision. (D) Any incident which threatens the welfare, safety or health of any resident...
This requirement is not met as evidenced by:
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Licensee/Administrator will review Title 22 Sec. 87211 and agreed to provide training to staff pertaining to CCLD reporting Requirements. Licensee will provide to LPA a sign-in sheet with staff signatures as proof that staff attended training by the POC due date: 11/18/22.
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Based on record reviews and interviews, the licensee did not comply with the section cited above. The facility failed to submit written report serveral falls and injuries of resident #1. This violation poses an immediate health, safety or personal rights risk to persons in care.
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Type B
11/18/2022
Section Cited
CCR
87608(5)
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87608 Postural Supports
(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet.

This requirement is not met as evidenced by:
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Licensee/Administrator will review Title 22 Sec. 87608 and agreed to provide training to staff pertaining to CCLD postural supports. Licensee will provide to LPA a sign-in sheet with staff signatures as proof that staff attended training by the POC due date: 11/18/22.
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Based on observation and interviews, the licensee did not comply with the section cited above. The facility tied a sheet to restraint resident #1 in wheelchair. This violation poses an immediate health, safety or personal rights risk to persons in care.
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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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC9099 (FAS) - (06/04)
Page: 8 of 10
Control Number 11-AS-20220209105823
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/18/2022
Section Cited
CCR
87705(5)(A)
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87705 Care of Persons with Dementia
(5) Each resident with dementia shall have an annual medical assessment...Medical Assessment, and a reappraisal done at least annually... (A) When any medical assessment, appraisal, or observation indicates... changed, corresponding changes shall be made in the care and supervision provided to that resident.
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Licensee/Administrator will review Title 22 Sec. 87705 and agreed to review and understand the requirements in this section. Licensee will provide to LPA a written statement as proof that this section was review and will comply by POC due date: 11/12/22.
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This requirement is not met as evidenced by: Based on record reviews, and interviews, the facility failed to conduct an annual medical, appraisal, and needs services for resident #1 who was diagnosed with dementia. This violation poses/posed a potential health, safety, or personal rights risk to persons in care.
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Type B
11/18/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations...

This requirement is not met as evidenced by:
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Licensee/Administrator will review Title 22 Sec. 87468.1 and agreed to review and understand the requirements in this section. Licensee will provide to LPA a written statement as proof that this section was review and will comply by POC due date: 11/18/22.
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Based on record reviews, and interviews, the facility failed to ensure the safety of resident #1 of falls and injuries. The faciltiy did not have a fall plan in place. This violation poses/posed a potential health, safety, or personal rights risk to persons in care.
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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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC9099 (FAS) - (06/04)
Page: 9 of 10
Control Number 11-AS-20220209105823
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/18/2022
Section Cited
CCR
87405(b)(1)(2)
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87405 Administrator - Qualifications and Duties (b) The administrator of a facility.. shall have the responsibility and authority to carry out the policies... (1) Knowledge of the requirements for providing care and supervision... (2) Knowledge of and ability to conform to the applicable laws, rules and regulations.
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Licensee/Administrator will create a plan to ensure that the administrator performs knowledge of and conforms to applicable laws, rules and regulations. Plan of correction will be submitted by POC due date: 11/18/22.
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This requirement was not met as evidenced by: Based on observation record reviews, and interviews, the Administrator failed to adhere to Title 22 regulations, resulting to multiple deficiencies cited. This violation poses/posed a potential health, safety or personal rights risk to persons in care.
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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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2022
LIC9099 (FAS) - (06/04)
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