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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 06/15/2023
Date Signed: 06/15/2023 03:28:06 PM

Substantiated


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
06/13/2023 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230613163216
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: 171DATE:
06/15/2023
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Ginger Enriquez TIME COMPLETED:
02:06 PM
ALLEGATION(S):
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Staff did not ensure facility was free from cockroaches.
Facility is in disrepair.
INVESTIGATION FINDINGS:
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On 06/15/23, 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: Interviews with staff #1-#4 (S1-S4), a review of (R1's) service records and other pertinent documents associated with this complaint. An inspection of the facility including room #203.

(Evaluation Report continues on LIC 9099-C)
Substantiated
Estimated Days of Completion:
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
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 6
Control Number 11-AS-20230613163216
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: 06/15/2023
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff did not ensure facility was free from cockroaches.

The details of the complaint alleged the staff is not ensuring the facility is free from cockroaches in the kitchen and throughout the facility. The Department inspected the kitchen, and commons areas in the Assisted Living and Arbor Hall Memory Care spaces and observed dead roaches in the dining room area. Staff #1 stated the pest control company was just out on 06/12/23 to spray in the kitchen and dining area is the apparent reason for the dead roaches. Staff #1-#2 (S1-S2) reported the facility has a service contract agreement with Gam Exterminating Inc. which comes to service the facility weekly. The facility provided maintenance service receipts as proof of service provided continuously. Based on the information gathered, there is sufficient evidence to support the allegation mentioned above.

Allegation: Facility is in disrepair.

The complainant alleged that resident #1 (R1’s) bathroom is not maintained in good repair. The complainant stated (R1’s) #203 bathroom toilet leaks, a sink is not working, a stained floor, and no shower curtain is provided. The Department inspected room #203 at 10:30 am and observed a rusted leaky faucet, a stained floor, a loose toilet flush, blue-green stain in the bottom of the sink. (R1’s) the bathroom did include a shower curtain which was observed during the inspection.

Neither the complainant nor resident #1 (R1) were available for further comment.



The Department inspected the common areas and observed a non-working carbon monoxide in the kitchen dangling a loose surveillance camera unattached to a ceiling bracket. Based on the information gathered, there is sufficient evidence to support the allegation mentioned above.

Based on observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D.

Exit interview was conducted with Ginger Enriquez, Assistant Administrator and a hard copy of the report along with appeal rights.

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
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
06/13/2023 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230613163216

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: 171DATE:
06/15/2023
UNANNOUNCEDTIME BEGAN:
08:55 AM
MET WITH:Ginger Enriquez TIME COMPLETED:
02:06 PM
ALLEGATION(S):
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9
Staff are not cleaning resident's bathroom.
Staff did not ensure the facility was not malodorous.
INVESTIGATION FINDINGS:
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On 06/15/23, 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: Interviews with staff #1-#4 (S1-S4), residents #2-#10 (R1-R10) a review of (R1's) service records and other pertinent documents associated with this complaint. An inspection of the facility including room #203.

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: 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
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20230613163216
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: 06/15/2023
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:
Allegation: Staff are not cleaning resident’s bathroom.

The details of the complaint alleged the staff is not ensuring the facility is not cleaning resident #1 (R1’s) bathroom. The Department inspected (R1’s) room #203 at 10:30 am and observed staff #3 (S3) was in (R1’s) room cleaning the bathroom. According to (S3) room #203 is on a daily housekeeping schedule which includes daily cleaning of (R1’s) bathroom. (R2) stated no issue with room #203 and it is service by housekeeping daily. An interview with staff #4 (S4) stated there is four (4) housekeeping staff on alternate schedules to service room #203 daily. (S4) stated that there are often when room #203 is serviced more than once a day when requested by residents and that housekeeping will provide the additional service. (S1) provided a Personnel Report LIC 500 which indicates the housekeeping staff schedules. The residents (R2-R10) reported they had no concerns as their rooms are service daily or as needed and did not feel neglected. Based on the information gathered, there is no evidence to support the allegation mentioned above.

Allegation: Staff did not ensure the facility was malodorous.

The complainant alleged that resident #1 (R1’s) bathroom and the facility smelled of malodorous urine. The Department inspected (R1’s) room #203 and found did not emit any malodorous odor. An inspection of common restrooms and areas of the facility found no malodorous odor. The Department has had six (6) plant inspection visits since January 2023. The Department observed the facility to be clean and maintained in order. During the visits on 06/15/23 and other prior visits, the Department has regularly observed housekeeping, janitorial, and maintenance services being conducted. An interview with (S4) expressed that they continue to ensure that the facility is in healthful conditions due to COVID-19 infection and extra work has been arranged by housekeeping staff to ensure the facility is a safe and sanitary environment for staff and residents daily. The residents (R2-R10) report they are pleased with the upkeep of the facility and state their rooms and common areas are not neglected. (R2-R10) added they have not observed the facility in a malodorous odor that would be considered offensive. Based on interviews and observation, there is no evidence to support the allegation mentioned above.

Neither the complainant nor resident #1 (R1) were available for further comment.



(Evaluation Report continues LIC 9099-C)
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
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20230613163216
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: 06/15/2023
NARRATIVE
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Based on information gathered, an inspection of the facility, observation, and interviews conducted, the Department found no evidence to support the allegations 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.
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
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20230613163216
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/15/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/16/2023
Section Cited
CCR
87303(a)
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(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:
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LIcensee/Administrator will need to replace/repair the carbon monoxide, clear dead pest from fumigation, and attached camera to ceiling bracket. Proof of correction must be sent to LPA by email in a video at ernand.dabuet@dss.ca.gov by 06/16/23.
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Based on [(observation), the licensee did not comply with the section cited above. LPA identified a non-working carbon monoxide, dead pest, and dangling unattached camera. This violation] which poses an immediate health, safety or personal rights risk to persons in care.
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Corrected during visit on 06/15/23
*Repeat Violation Immediate $250.00*
Type B
06/29/2023
Section Cited
CCR
87303(a)(1)(e)(6)
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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. (1) Floor surfaces in bath...shall be maintained in clean, sanitary, and ordorless condition. (e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition....equipment shall be provided in facilities acoomodating physically handicappedand/or a non-ambulatory residents...
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LIcensee/Administrator will need repair leaky rusted faucet, remove stained in sink and floor and repair toilet flush for room #203. Proof of correction must be sent to LPA by email in a video at ernand.dabuet@dss.ca.gov by 06/29/23
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Based on [(observation), the licensee did not comply with the section cited above. LPA identified a rusted leaky faucet, stained floor/sink, and loose toilet flusher. This violation] which poses a potential health, safety or personal rights risk to persons in care.
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Amended: This report serves as an amendment to clarify subsections missing on second citation. It does not supersedes the complaint investigation findings reflected on report created on 06/15/23.
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: 07/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6