198204950-9-11-2023-11-AS-MVAO-CVLVAY-20230912161644

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 09/08/2023
Date Signed: 09/11/2023 07:57:58 AM

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
12/17/2021 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20211217084833

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: 168	DATE:	09/08/2023
		UNANNOUNCED	TIME BEGAN:	12:31 PM
MET WITH:	Ginger Enriquez		TIME COMPLETED:	04:02 PM

ALLEGATION(S):

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Resident sustained multiple pressure injuries while in care.

INVESTIGATION FINDINGS:

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On 09/08/23 Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced complaint visit at this facility, LPA was greeted by administrator Ginger Enriquez. LPA explained the purpose of today's inspection visit is to gather additional information and deliver findings for the allegation mentioned above.

The investigation consisted of the following: LPA obtained copies of the roster for residents and staff. Service records for residents #1 (R1) and Medication Administration Records (MARs) were included, along with home health records, hospital records. skilled nursing records, and other pertinent documents associated with this complaint. Interviews were conducted with residents #1-#10 (R1-R10), staff #1-#5 (S1-S5) and witness #1 (W1). A tour of the entire facility was performed on 12/17/21, 04/04/22, 04/18/22, and 09/08/23.

(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: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

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-20211217084833

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: 09/08/2023

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Resident sustained multiple pressure injuries while in care.

The details of the complaint alleged resident # 1 (R1) sustained multiple pressure injuries while in care at this facility. As reported on the Report of Suspected Dependent Adult/Elder Abuse (SOC 341) form. Specifically, the complaint focused on an incident that occurred on 12/14/21 when (R1) was hospitalized at Harbor UCLA Medical Center Hospital. Indicated on the (SOC-341) (R1) presented multiple wounds described in various stages from unstageable to wound healing in Stage 3. In medical records, a total of (15) wounds were identified. The Department reached out to the complainant for further comments but was not available.

The Admissions Agreement indicated (R1) was admitted at Carson Senior Assisted Living (CSAL) on 04/19/21. (R1) was medically assessed according to (R1’s) Physician’s Report dated 04/19/21 as ambulatory in fair physical health status. (R1’s) capacity for self-care required assistance with activities of daily (ADL) however did not require continuous bed care and a history of skin breakdown. According to service records (R1) was admitted on 04/20/21 by St. Paul Home Health Services (SPHHS). Home health services included services 2 or 3 visits weekly by a licensed registered nurse who attended to (R1’s) medical health condition that included a wound care order. The medical records for (R1) presented between 04/19/21 to 12/14/21, (R1) transitioned between hospitals, skilled nursing homes, and Carson Senior Assisted Living (CSAL). As a result of these transitions, (R1’s) wound care orders remained consistent with St. Paul Home Health Services. Each time (R1) was readmitted back at (CSAL), (SPHHS) was reinstated.

In accordance to a Medical Body Assessment and Body Documentation for (R1), wound assessment and care was conducted on 09/24/21, 10/14/21, 11/23/21, 11/24/21, 12/04/21 by (CSAL) (SPHHS) and Omni Wound Physicians (OWP). The West Coast Wound Company conducted an additional wound assessment and wound treatment plan on 12/02/21. No wounds were classified as stage 3 or stage 4 in any of the assessments.

(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: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20211217084833

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: 09/08/2023

NARRATIVE

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Staff #1-#2 (S1 and S2) provided a written Declaration dated 04/14/22 indicating confirmation (R1) had continuous wound care under (SPHHS) and throughout transitions between hospitals, skilled nursing homes, and (CSAL).

Interviews with (3) out (5) staff #3-#5 (S3-S5) on 04/18/22 all verified body assessments were conducted regularly and noted on charts for (SPHHS) and home health notified. (S3-S5) reported (R1) was able to reposition was not bedridden and was not neglected in care or supervision.

On 04/04/22, the Department interviewed (9) out (166) residents #2-#10 (R2-R10) who had no pressure injuries and were complimentary of care staff. (R2-R10) reported care staff are caring, accountable, and responsive to residents in care.

On 08/23/23, the Department interviewed resident #1 (R1) who is being cared for at Country Villa Belmont Heights Healthcare Center confirmed (R1) was on home health. When (R1) was a resident at (CSAL) that home health was assisting with (R1’s) wounds. (R1) reported the staff at (CSAL) were fair and they assisted when home health was not available. (R1) did not feel neglected and received assistance until (R1) required a higher level of care.

(R1) stated that (R1) always had wounds and it was being addressed at (CSAL) to prevent further infections. (R1) stated (R1) was able to reposition (R1) in bed and was not considered as bedridden. (R1) does not hold the (CSAL) responsible for the wounds as (R1) was being assisted by home health services along with care staff at (CSAL).

Based on information gathered, an inspection of the facility, observation, analysis of (R-1)'s service records medical records, and home health records, Declarations, and interviews conducted, the Department found no evidence to support NEGLECT OR LACK OF SUPERVISION: Resident sustained multiple pressure injuries while in care is Unsubstantiated.

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 as a result, the allegation is Unsubstantiated.

An exit interview was conducted with Ginger Enriquez and a copy of the report was provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 09/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023

LIC9099 (FAS) - (06/04)

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