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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204950
Report Date: 04/25/2023
Date Signed: 04/25/2023 06:54:07 PM


Document Has Been Signed on 04/25/2023 06:54 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: 162DATE:
04/25/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:11 PM
MET WITH:Ginger Enriquez TIME COMPLETED:
03:37 PM
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On 04/25/23 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 about the death of (R1).

The regional office received a copy of the death report from the facility and reported the death of (R1) on 04/21/23. The death report stated on 04/20/23 (R1) was pronounced dead at 2:00 a.m. at Harbor UCLA Medical Center. Castro was sent to the hospital on a emergency medical services (EMS) and was admitted at the hospital on 04/19/23 due to a fall in the resident's bathroom in the facility. At 5:10 a.m., Castro's roommate resident #2 (R2) contacted (EMS) directly. The facility is unable to obtain detail information surrounding the cause of the death as it is under investigation. Interviews conducted with staff #1-#3 (S1-S3) and resident #2 (R2) were performed on this visit.

The following documents were collected:
ID and Emergency Information,
Admission Agreement
Physical Health Intake Assessment,
Physician Report for Community Care Facilities,
Resident Appraisal
Appraisal/Needs and Service Plan
Medications (MAR)
Medical Treatments (Carson Avalon Dialysis, Harbor UCLA, Providence of Mary)
Food menu

An exit interview was 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: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023
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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