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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204950
Report Date: 08/18/2023
Date Signed: 08/18/2023 04:01:19 PM


Document Has Been Signed on 08/18/2023 04:01 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: DATE:
08/18/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:07 PM
MET WITH:Ginger Enriquez TIME COMPLETED:
03:29 PM
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On 08/18/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent case management visit at this facility. LPA met with assistant administrator Ginger Enriquez and explained the purpose of the visit. LPA is to issue the final results of the death investigation of resident #1 (R1).

The regional office received a copy of the death report from the facility and reported the death of (R1) on 04/24/23. The death report stated on 04/19/23 (R1) was found by roommate resident #2 (R2) in the bathroom laying on the floor at 5:00 am. (S2) called 911 immediately and (R1) was transported to Harbor UCLA Medical Center. The facility was notified by family member that (R1) was pronounced dead after one day of observation at the hospital. The Department interviewed the (R2), staff #2 (S2) and administrator Ginger Enriquez staff #1 (S1).

Medical records from Harbor UCLA Medical Center and a death certificate revealed that (R1’s) cause of death was due cardiopulmonary arrest. Based on information gathered, the Department found no evidence of negligence or foul play by the facility and will now close this investigation.

An exit interview with Ginger Enriquez and a copy of the report was provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 08/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/18/2023
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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