198204950-11-28-2022-11-AS-MVAO-CM5VAH-20221215151558

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 11/28/2022
Date Signed: 11/28/2022 09:18:32 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
11/22/2022 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20221122161220

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: 170	DATE:	11/28/2022
		UNANNOUNCED	TIME BEGAN:	09:03 AM
MET WITH:	Ginger Enriquez		TIME COMPLETED:	03:33 PM

ALLEGATION(S):

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Facility staff failed to provide resident records to the residents authorized representative.

INVESTIGATION FINDINGS:

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On 11/28/22, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced complaint visit at this facility, LPA was greeted by Assistant Administrator Ginger Enriquez. LPA explained the purpose of the visit is to investigate the allegation mentioned above.

The investigation revealed the following: The complainant requested an investigation concerning resident #1 (R1) who formerly resided at this facility. According to the complainant, the facility failed to provide the service records requested to (R1's) representatives due on 11/16/22. These records were requested on 11/14/22 from the facility sent by Federal Express. The Department interviewed administrator Joel Goldman staff #1 (S1) and assistant administrator Ginger Enriquez staff #2 who verifed the request arrived by Federal Express late on 11/17/22. While the written request was dated 11/14/22, it was received after the due date of 11/16/22. As per (S1), all legal requests are forwarded to the facility's legal representatives.

Evaluation Report continues on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022

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-20221122161220

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: 11/28/2022

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

(S1) stated as soon as the request was received via Federal Express late on 11/17/22, it was immediately discussed with the facility's litigation manager, that the legal firm will respond to this request. (S1) reported following up with the litigation manager on 11/22/22 and was informed the case was being processed. At the time of 11/28/22, the Department contacted the complainant, who could not verify whether the facility's legal representative had been contacted. Based on the information gathered, there is insufficient evidence to support the facility's disregard or failure to provide (R1's) service records as requested by the authorized representative.

Based on information gathered, an inspection of the facility, observation, and interviews conducted, the Department found no evidence to support the allegation mentioned above.

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 allegations is 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: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 11/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022

LIC9099 (FAS) - (06/04)

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