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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204950
Report Date: 05/13/2023
Date Signed: 05/15/2023 09:36:04 AM


Document Has Been Signed on 05/15/2023 09:36 AM - 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: 166DATE:
05/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ginger Enriquez TIME COMPLETED:
04:59 PM
NARRATIVE
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On 05/13/23 Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Administrator Ginger Enriquez. LPA Dabuet explained the purpose of today’s visit. The facility is licensed to operate for (230) non-ambulatory elderly adults of which (10) may be bedridden ages 60 and above. Currently, the facility has (166) residents and (2) in hospice care. The facility is approved for (10) hospice residents.

The facility is a two story structure located in a commercial neighborhood. It consists of the following: (35) resident bedrooms in Arbor Unit and (99) resident bedrooms in Assisted Living. Each room has a bathroom in the unit, an activity room, a dining area, a kitchen, and outside patio area.

LPA toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were stocked during the visit. The resident rooms were inspected: #274, #203, #264, #4B, #30A #4A,,#231, #223, #235 #246, #247 and #267. All call buttons were in working condition. Bathrooms were operational with water temperature measured at 105.7 – 111.4 degrees F. A comfortable temperature was maintained in the facility at 72 - 74 degrees F.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately.

Evaluation Report continues LIC 809-C
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 05/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/13/2023
NARRATIVE
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Fire extinguishers were charged, and smoke detectors and carbon monoxide were operable in each resident's room. A review of the Medication Records Administration (MAR) was observed to be maintained in order and accurately. During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA conducted an audit of resident #1-#6 (R1-R6) service files, and staff #1-#7 (S1-S5) personnel files were in order and complete. LPA conducted (6) resident and (3) staff interviews.

DEFICIENCIES:
LPA observed a non-operational smoke detector outside the activity room in memory care. LPA observed two (2) kitchen stove burners not working.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 9099-D).

An exit interview conducted with Ginger Enriquez and a copy of report and appeal rights provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *

This report serves as an amendment to clarify finding. It does not supersedes the evaluation report findings reflected on report created 05/13/23.

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

DATE: 06/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/15/2023 09:36 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(a)
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation), the licensee did not comply with the section cited above. LPA identified a non-working smoke detector missing outside the activity room in memory care. This violation] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2023
Plan of Correction
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LIcensee/Administrator will need to replace/repair the smoke detector. All smoke dectectors must be in working condition. Proof of correction must be sent to LPA by email in a video at ernand.dabuet@dss.ca.gov by 04/15/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 05/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 05/15/2023 09:36 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(29)
(29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) the licensee did not comply with the section cited above. LPA identified kitchen stove rear and front burners not working condition and required a match to operate. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/13/2023
Plan of Correction
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Licensee/Administrator will ensure that all food service equipment are in working condition and have the rear and front stove burners repaired. Proof of correction must be sent to LPA with a repair/invoice receipt by email at ernand.dabuet@dss.ca.gov by 06/13/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 05/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/13/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4