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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 09/29/2023
Date Signed: 10/02/2023 10:47:06 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
09/01/2023 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230901110928
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: 168DATE:
09/29/2023
UNANNOUNCEDTIME BEGAN:
08:09 AM
MET WITH:Ginger Enriquez TIME COMPLETED:
12:28 PM
ALLEGATION(S):
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Staff did not seek medical attention for resident.
Staff did not provide resident with his P&I.
Staff are not meeting resident's hygiene needs.
Staff are not meeting resident's laundry needs.
INVESTIGATION FINDINGS:
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On 09/29/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent complaint visit. LPA was greeted by administrator Ginger Enriquez. This inspection visit is to gather information for the allegations mentioned above and deliver findings.

The investigation consisted of the following: A review of the facility's roster for residents and staff. Interviews with residents #1-#10 (R1-R10), witnesses #1-#6 (W1-W6, and staff #1-#4 (S1-S4). A review of (R1's) Service Records, Shower List Log, Activity Monitoring Log, Daily Body Check Report, Incontinence Check Log, Resident Safeguarded Cash Resources LIC 405, SSI Supplemental Security Income, SSA Retirement Surviors and Disability Insurance, and other pertinent documents associated with this complaint. A
physical tour of the facilty was conducted 09/08/23 and 09/08/27.

(Evaluation Report continues 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: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
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 5
Control Number 11-AS-20230901110928
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: 09/29/2023
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: Staff did not seek medical attention for resident.

The details of the complaint alleged that resident #1 (R1) had a swollen ankle and that staff did not seek medical attention. The complainant described (R1’s) left ankle was swollen in August 2023 while doing exercises and that administrator did not seek medical treatment.

The Department interviewed (R1) at 9:30 am on 09/27/23. (R1) claimed was never injured during an exercise activity and can walk with no issues. (R1) denied ever having the left ankle injured. During the investigation visits on 09/15/23 and 09/27/23, (R1) was observed walking through the hallway with a walker properly and with no difficulties.

On 09/27/23 between 11:00 am – 02:59 pm (4) staff out (4) staff #1-#4 all denied that (R1) had ever reported of injuries. (S1) claimed to be unaware making statement about (R1's) injuries to any individuals. (S1-S4) stated if staff had knowledge (R1’s) injuries, it would have been reported and documented. “Daily Body Check Report” is completed by staff, and this would have been addressed with the in-house physician.

Interviews conducted between 10:01 am – 3:11 pm with (9) out (9) residents #2-#10 (R2-R10) had no concerns or issues receiving medical assistance timely. (R10) stated that facility staff are proactive and have made improvements by training staff in medical procedures and have been responsive.

Interviews conducted between 10:37 am – 12:43 pm with (6) out (6) family representatives witness #1-#5 (W1-W6) reported they did not have any concerns for the health and safety for the residents. (W1-W6) described the care and supervision as sufficient.

The Department reviewed the medical assessments reports for (R1) (dated: 08/23/23 and 08/30/23), revealed (R1) had no muscle weakness, was stable, and no falls reported. The Body Check Report” (dated: 08/01/23 – 08/31/23) did not indicate any bodily injury for (R1). Therefore, based on all the information obtained during the investigation, there is no evidence to support the allegation mentioned above.

(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: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20230901110928
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: 09/29/2023
NARRATIVE
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Allegation #2: Staff did not provide resident with his P & I.

It is alleged that staff withholds resident #1 (R1's) Personal and incidental cash resources. The complainant reported (R1) receives a monthly $322 from the Social Security Administration. The complainant claims the staff is withholding (R1's) cash resources because of overdue balances for (R1) basic services. The complainant also is unclear on what the facility is charging (R1) for basic services.

(R1) was admitted on 06/18/21 according to the Admission Agreement (dated: 06/18/22). (R1) has no conservative or power of attorney listed on record. The basic services rate was $ 1,079.32 for a shared room in the assisted living section. A Physician's Report (dated: 04/04/22) required for (R1) needing services in the memory care section in Arbor Hall. (R1) was transferred to a private room in 08/2021 in Arbor Hall after being hospitalized in July 2023 with physician's orders. The basic services is $4500.00 in Arbor Hall. The facility is not charging (R1) $4500 per month for services and a private room, instead the facility is only charging by California Assisted Living (CALA) requirements effective 01/01/23 $1344.82. The facility is only authorized by (CALA) the following: Room and board $64.82; Care and Supervision $678; SSI/SSP $20 for total basic services payable $1344.82.

(R1) is paid each month by (SSI/SSP): Supplemental Security (SSI) $914; State Supplementary Payment (SSP) $578.82 total for Non-Medical Out of Home (NMOHC) payment standard is $1492.82. Once the basic services of $1344.82 are deducted, (R1's) Personal and Incidental (P&I) allowance is $168 each month. According to staff #1 (S1) the facility was granted as the payee for (R1's) SS1/SSP benefits from 06/2023 - 08/2023. The payee was changed to (R1's) family representative effective 09/1/23. With the current changes in payee, the facility has not been paid for September 2023. A review of (R1's) Record of Resident's Safeguarded Cash Resources LIC 405 for 2023 indicates that (R1) has a (P&I) credit balance of $504.00.

The Department interviewed (R1) at 9:30 am on 09/27/23. (R1) claimed not to handle finances and that it is being handled by a family member. (R1) confirmed receiving (P&I) money from the business office when requested. (R1) only request for $20 only has needed as (R1's) preference. (R1) explained there is no need for additional money as everything is here at the facility.

(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: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20230901110928
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: 09/29/2023
NARRATIVE
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Interviews conducted between 10:01 am – 3:11 pm with (9) out (9) residents #2-#10 (R2-R10) had no issues related to finances. (R7-R10) stated they handled their finances.

Interviews were conducted between 10:37 am and 12:43 pm with (6) out (6) family representatives witness #1-#5 (W1-W6) reported that family members handled cash resources for residents. Therefore, based on all the information obtained during the investigation, there is no evidence to corroborate the allegation mentioned above.

Allegation #3: Staff are not meeting resident’s hygiene needs.
Allegation #4: Staff are not meeting resident’s laundry needs.

According to the complaint report, resident #1 (R1) was not bathed and was wearing dirty clothes. The complainant described (R1’s) hygiene as not being met and was seen in dirty clothes and socks. The complainant did not elaborate on details nor provided the date or time when (R1) was seen in this state.

In the Department's observations on 09/15/23 and 09/27/23, (R1) appearance on both occasions were pleasant. On 09/15/23 at 11:30 am while (R1) was in line for a lunch meal, (R1) was dressed in a plain dark navy blue sweatshirt and denim jeans. On 09/27/23 at 9:30 am was seen in a T-shirt and a plaid pants while watching television. (R1) appeared to be in clean clothing and well-groomed. (R1) was interviewed on 09/27/23 at 9:30 a.m. and reported no issues with hygiene assistance from staff. (R1) indicated being bathed three times a week, and laundry is done by staff weekly.

On 09/27/23 between 11:00 am – 02:59 pm (4) staff out (4) staff #1-#4 confirmed that (R1) is being assisted with hygiene weekly. (S1-S2) denied (R1’s) ever appeared in disheveled or unclean clothes. (S1) claimed the clothes on (R1) are donated and not purchased by (R1) or (R1's) family members. Donated clothing may often present the appearance that it is not of the best quality or condition according to (S1).

Interviews conducted between 10:01 am – 3:11 pm with (9) out (9) residents #2-#10 (R2-R10) verified to not having issues with lack of assistance with hygiene or laundry services. (R7-R10) claimed to be independent and can self-care for themselves.

(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: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20230901110928
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: 09/29/2023
NARRATIVE
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(R10) expressed having preference to wash one's laundry, since (R10) prefers not having clothing handled by others.

Interviews were conducted between 10:37 am and 12:43 pm with (6) out (6) witnesses #1-#6 (W1-W6) reported no issues with resident's hygiene requirements being met. (W1-W6) had no issues with the resident's clothes being laundered by the facility.

A review of the facility’s Shower List Log (dated: 08/01/23 – 08/31/23) indicated that (R1) is given pm showers on Monday, Wednesday, and Friday (3) times a week initiated by staff. (R1) is being monitored for “Incontinence (2) Hour Check” from 8 am – 9 pm and for “(1) Hour Activity Monitoring” from 7 am – 10 pm marked by staff on record along with “Daily Body Check Report”. Therefore, based on all the information obtained during the investigation, there is no evidence to support the allegations mentioned above.

Based on information gathered, an inspection of the facility, observation, and interviews conducted, an analysis of records reviewed, the Department found no evidence to support the allegations mentioned above.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation, 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 HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5