198204950-2-11-2021-11-AS-MVAO-BYRN8E-20210303091412

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 02/06/2021
Date Signed: 02/11/2021 11:59:10 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/16/2020 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20201116120001

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: 153	DATE:	02/06/2021
		UNANNOUNCED	TIME BEGAN:	10:01 AM
MET WITH:	Ginger Enriquez		TIME COMPLETED:	11:35 AM

ALLEGATION(S):

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The facility mismanaged the resident's medications.

INVESTIGATION FINDINGS:

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On 02/06/21 Licensing Program Analyst, (LPA) Ernand Dabuet initiated a complaint investigation for the allegations listed above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s subsequent complaint investigation was conducted telephonically with Ginger Enriquez/Administrator at this facility.

The investigation consisted of the following: Interviews conducted with staff (S1-S2), resident (R1), and witnesses (W1-W2). A review of (R1's) service records and other pertinent documents relevant to this complaint. A plant inspection of the facility was conducted on 11/18/20 and 02/06/21.

Evaluation Report continues on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2021

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-20201116120001

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
	VISIT DATE: 02/06/2021

NARRATIVE

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Investigation Revealed:
Allegation: The facility mismanaged the resident's medications.

The Department conducted interviews with resident #1 (R1), staff #1 and #2 (S1-S2), and witnesses #1 and #2 (W1-W2) together with a review of (R1’s) service records and other documents relevant to this complaint and found there is no evidence to corroborate the allegation mentioned above.

It was alleged the facility mismanaged (R1’s) medications. An interview with (R1) claims this is all a misunderstanding and that Carson Senior Assisted Living is not responsible for mismanaging his medications. According to (R1) he recently moved to this facility on 10/01/20 and has not encountered any problems with how the facility manages his medications. During the interview with (R1), he admitted that he was frustrated with his physician as he refuses to see the resident for an in-person visit and that his physician controls his refills and quantity of his medications. He explains that he admitted himself to the emergency ward at Little Company of Mary’s in Torrance in November 2020. The reason was to get himself refills for his medications. (R1) explains he did not handle the situation properly. (R1) also included in his statement that there is no type of suspicious activity or fraud at this facility. (R1) stated when his information was being transcribed at the hospital, he was referring to his physician and the former skilled nursing facility he resided before Carson Senior Assisted Living. An interview with (W1) was not able to provide additional information on the allegation. A statement from (W2) did confirm that (R1’s) medications are controlled by his physician and not the facility. (W2) added (R1) has not encountered any problems with this facility and is pleased with his living conditions. An interview with (S1-S2) both confirmed that (R1’s) medications are reordered with the authorization of his physician and when (R1) transferred to this facility a 30-day supply was on hand. A confirmation of this was verified with a review of (R1’s) Medication Administration Record where it showed medications were administered daily. During the interview with (R1) and (S1-S2) all verified that (R1) is self responsible for making his medical appointments. Based on the Department’s observation, interviews, and a review of service records that were conducted, the Department found there is no evidence to support the allegation mentioned above.

Evaluation Report continues on LIC 9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2021

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20201116120001

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
	VISIT DATE: 02/06/2021

NARRATIVE

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Based on information gathered, the Department did not find sufficient evidence to support the allegation: “The facility mismanaged the resident's medications.”

Although the allegation may have happened or is valid, there is not enough preponderance of evidence to prove the alleged allegation is valid did or did not occur. Therefore, the allegation is "unsubstantiated.”

A telephonic exit interview was conducted with Ginger Enriquez, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2021

LIC9099 (FAS) - (06/04)

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