198204950-3-19-2023-11-AS-MVAO-CQ8SVB-20230324141229

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 03/17/2023
Date Signed: 03/19/2023 10:43:18 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
03/15/2023 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230315161813

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: 165	DATE:	03/17/2023
		UNANNOUNCED	TIME BEGAN:	08:58 AM
MET WITH:	Ginger Enriquez		TIME COMPLETED:	03:59 PM

ALLEGATION(S):

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Faciltiy failed to provide adequate supervision to residents in care.

INVESTIGATION FINDINGS:

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On 03/17/23, 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-#2 (R1-R2). LPA obtained copies of the facility roster for residents and staff. Interviews conducted with Resident #1-#10 (R1-R10), staff #1-#4 (S1-S4), and witnesses #1-#3 (W1-W3). A reviewed of (R1 and R2)'s service records and other pertinent documents pertinent to the allegation on this complaint. A tour of the facility was performed. (Evaluation Report continues on LIC 9099-C

This report serves as an amendment to clarify finding in line #7. It does not supersedes the complaint investigation findings reflected on report created on 03/17/23.

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: 03/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2023

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-20230315161813

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: 03/17/2023

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Facility failed to provide adequate supervision to residents in care.

During this investigation, The Department reviewed (R1-R2)’s service records and interviewed staff #1-#4 (S1-S4) and residents #1-#10 (R1-R10) and found there is no evidence to support the allegation mentioned above.

(R1-R2) both were admitted on 03/13/23 to local hospitals for injuries. (R1) shared room #212 with (R2). (R1) had an incident with (R2) on 03/13/23 inside their shared room. (R1) reported that (R2) attacked (R1) on 03/13/23 over a foul-smelling diaper. Upon asking (R2) to tie the diaper in a knot, (R2) attacked and bit (R1), and attempted to cover (R1) mouth. (R1) admitted, biting (R2) out of self-defense. (R1) claimed to scream and it alerted a staff that (R1) was being attacked and the staff came to break up the physical altercation. (R2) was interviewed did not want to offer any information on the incident and did not admit that a physical altercation had occurred with (R1). (R2) just kept responding, "(R1) was just nasty". Interviews with witnesses #1-#3 (W1-W3) authorized family representatives were unable to verify if there has been a history of tensions or incidents between the (R1 and R2) that could have prevented the incident on 03/13/23.

An interview with staff #1-#4 (S1-S4) revealed that the facility did its due diligence and reported the incident in an incident report to Community Care Licensing (CCL), Law Enforcement, Long Term Ombudsman, and the resident's authorized representatives. The facility conducted interviews with both residents and was given separate rooms. Interviews with residents #3-#10 (R3-R10) all claim they felt safe and secure at this facility and were not aware of any physical altercations with residents. Furthermore, they all felt the staff is attentive to their needs and safety. The Department through interviews with residents and staff revealed there were no witnesses that observed the incident on 03/13/23. According to the administrator, this is a one-time occurrence. The facility had no prior knowledge of mounting tensions between residents, nor any prior history exhibited of this behavior with both residents. (R1) and (R2) did not require one on one care and are both independent.

The Department acknowledged an altercation occurred and that (R1) did not want to file criminal charges. However, there is no evidence of a violation for neglect/lack of care or supervision as both residents did not require constant supervision, had no prior incidents, and the facility acted immediately and did what was necessary. ( Evaluation Report continues LIC-9099-C)

This report serves as an amendment to clarify finding in line #3. It does not supersedes the complaint investigation findings reflected on report created on 03/17/23.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230315161813

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: 03/17/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. No Deficiencies were cited under the California Code of Regulations (Title 22 Division 6 Chapter 8). An exit interview was 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: 03/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2023

LIC9099 (FAS) - (06/04)

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