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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 11/28/2022
Date Signed: 11/28/2022 09:17:59 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
11/21/2022 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20221121153327
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: 170DATE:
11/28/2022
UNANNOUNCEDTIME BEGAN:
10:22 AM
MET WITH:Ginger Enriquez TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff not providing residents as prescribed.
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 consisted of the following: LPA obtained copies of the roster for residents and staff. Interviews conducted with Resident #1-#10 (R1-R10), staff #1-#2 (S1-S2) 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: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (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)
Page: 1 of 2
Control Number 11-AS-20221121153327
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:

Allegation: Staff not providing residents as prescribed.

An investigation was requested by the complainant concerning resident #1 (R1)'s prescription medication not being provided by the staff. For the past six months, (R1)'s Parkinson's prescribed medications have not been supplied. There was limited details furnished by the complainant.

The Department reviewed (R1's) service records which include (R1's) prescribed medications. (R1) is prescribed four (4) Parkinson's medications daily at 5 am, 7 am, 12 pm, 3 pm, and 7 pm. A review of (R1's) Medication Administration Record (MAR) showed that (R1) has not skipped any Parkinson's medications including non-Parkinson meds. Evidence revealed that (R1) signed off daily when medications were administered. In an interview with (R1) who denied having any issues with medications. (R1) is aware the type and names of all medications prescribed by the primary physician. (R1) claimed there have been no missed dosages. An interview with staff #1 -#2 (S1-S2) both refuted this allegation. (S1-S2) reported (R1) suffers from memory loss and often will embellish circumstances. Residents #2-#10 (R2-R10) who claimed requiring medication assistance had no issues or concerns.

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 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 HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (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)
Page: 2 of 2