198204950-6-28-2023-11-AS-MVAO-CUYTBL-20230823143520

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 06/28/2023
Date Signed: 06/28/2023 10:41:52 PM

Unsubstantiated

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
05/12/2023 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20230512143338

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: 173	DATE:	06/28/2023
		UNANNOUNCED	TIME BEGAN:	11:04 AM
MET WITH:	Ginger Enriquez		TIME COMPLETED:	02:31 PM

ALLEGATION(S):

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Facility failed to supervise resident who wandered away from the facility.
Facility failed to safeguard residents cash resources.
Facility failed to administer medication as prescribe.
Facility is not kept clean.

INVESTIGATION FINDINGS:

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On 06/28/23 Licensing Program Analyst (LPA) Ernand Dabuet conducted an subsequent unannounced complaint visit at this facility, LPA was greeted by assistant administrator Ginger Enriquez. LPA explained the purpose of today's inspection visit and to gather information and deliver findings.

The investigation consisted of the following: LPA obtained copies of the roster for residents and staff. A review of service records for resident #1 (R1) and other pertinent documents associated with this complaint. Interviews with resident #1-#8 (R1-R10) staff #1-#3 (S1-S3), and witnesses #1 (W1) An inspection of the facility was conducted.

(Evaluation Report continues LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023

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 4

Control Number 11-AS-20230512143338

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: 06/28/2023

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Facility failed to supervise resident who wandered away from the facility.
According to the complaint, (R1) wandered away from the facility and accepted a ride from an unknown individual who brought (R1) to (R1)'s) destination. The Department reached out to the complainant but was not able to obtain further information on this matter.
As a result of an interview with (R1), (R1) recalled the incident, however (R1) is unable to provide details regarding how (R1) left the facility nor how (R1) got to the destination. (R1) does remember being transported back to the facility by staff. An interview with staff #1- #2 (S1-S2) confirmed that (R1) is ambulatory and capable of self-care of daily activities is not diagnosed with dementia. (R1) can leave the facility unassisted. It has been verified through a review of (R1's) Physician Report dated 04/05/23 that (R1) does not have wandering or confused behaviors and is able to leave the facility unassisted. An interview with (R1’s) family representative witness #1 (W1) verified that (R1) is able to leave the facility unattended. According to (S1) due to this incident, the facility requested for (R1) to be medically revaluated effective 05/17/23. Interviews with residents #2 -#10 (R2-R10) are independent residents had no concerns about supervision. Although (R2-R10) are independent residents, if supervision is required staff is able to assist. Based on the information gathered, there is no evidence to support the allegation mentioned above.

Allegation: Facility failed to safeguard residents cash resources.
It is alleged the facility failed to safeguard resident #1 (R1’s) cash resources. The complainant stated (R1) had a cashier’s check and cash that went missing while in the facility. (R1) did not recognize debit card transactions from State Farm and HBO from (R1's) card. In an interview with (R1), (R1) did not recall having cash missing or claiming unrecognized purchases on debit card. An interview with family representative witness #1 (W1) stated that (R1) does not handle finances. (W1) handles the finances for (R1). (W1) verified the purchases from Stated Farm and HBO are legitimate transactions and that (R1) did not have missing cash as (W1) handled (R1's) financial resources. According to (S2), the facility does not pay for residents’ internet, cable, car, or renter’s insurance as these are not part of the monthly basic services provided by the facility. These services are paid out of pocket by the residents.

(Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20230512143338

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: 06/28/2023

NARRATIVE

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(S2) confirmed that (W1) is responsible for (R1’s) finances, and (W1) pays for the services provided by the facility. Interviews conducted with (R2-R10) who are responsible for handling their finances expressed no problems with the facility safeguarding their property valuables. Based on the information gathered, there is no evidence to corroborate the allegation mentioned above.

Allegation: Facility failed to administer medication as prescribed.
It is alleged that resident #1 (R1) does not receive prescribed medications. The Department reached out to the complainant, however, was unable to obtain additional information on this matter.

The Department interviewed (R1) who claimed to have received all prescribed medications daily and timely. (R1's) Medication Administration Records (MAR) show that (R1) is medically prescribed nine (9) medications and five (5) pro re nata (PRN). The (MAR) revealed it to be accurate and complete. An interview with (S2) claimed there are no issues with the administration of medications for (R1). There have been no dosages refused or missed. According to the family representative witness (W2), (R1) has not had problems with any of (R1's) medications. Interviews with (R2-R10) claimed the med-techs are good at keeping them on track with their medications and had no concerns. Based on the information gathered, there is no support for the allegation mentioned above.

Allegation: Facility is not kept clean.
The details of the complaint claimed that resident # (R1) is forced to eat on dirty tables and the facility is not kept clean. The complainant did not provide additional information on this matter. As a result in an interview with (R1), (R1) does not recall making issues with unclean tables or unkempt facilities. According to family representative witness #1 (W1), (R1) has not raised issues with the cleanliness of the facility or being forced to eat at dirty tables. (W1) stated she is content with the care and supervision that the staff is providing for (R1) and did not have any concerns for (R1's) well-being.

An inspection of common areas on 05/12/23, 06/15/23, and 06/28/23 of the facility found the facility to be clean and sanitary. As observed by the Department, the facility was clean and well-maintained.

(Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20230512143338

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: 06/28/2023

NARRATIVE

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During the visits on 06/28/23 and other prior visits, the Department has regularly observed housekeeping, janitorial, and maintenance services being conducted. An interview with (S3) on 06/15/23 expressed that staff continues to ensure that the facility is in healthful conditions due to COVID-19 infection, and extra work arrangements with staff to ensure the facility is a safe and sanitary environment for staff and residents daily. Residents (R2-R10) report being satisfied with the facility's upkeep and that their rooms and common areas are not neglected. (R2-R10) added they have not observed the facility in disarray condition. Based on interviews and observation, there is no evidence to support the allegation mentioned above.

Based on the information collected, an inspection of the facility, observation, record reviews, and interviews conducted, the Department found no evidence to support the allegations in this complaint.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted with Ginger Enriquez, and copies of the reports were provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023

LIC9099 (FAS) - (06/04)

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