198204950-1-18-2024-11-AS-JHAD-D232Z2-20240201164937

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 01/18/2024
Date Signed: 01/18/2024 03:24:24 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/16/2024 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20240116151820

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:	01/18/2024
		UNANNOUNCED	TIME BEGAN:	08:01 AM
MET WITH:	Julie Villlaueva - Director of Resident Care		TIME COMPLETED:	03:32 PM

ALLEGATION(S):

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Facility failed to provide comfortable accomodations for residents in care.

INVESTIGATION FINDINGS:

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On 01/18/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced complaint visit at this facility. LPA was greeted by the Director of Resident Care Julie Villanueva. LPA explained the purpose of this visit is to gather information for the allegation mentioned above and deliver findings.

The investigation consisted of the following: A review of the facility's roster for residents and staff. Interviews with staff #1-#6 (S1-S6) and witness #1-(W1). A review of the heating and air condition/HVAC invoice and other pertinent records associated with this complaint. A physical tour of the facility was conducted.

(Evaluation Report continues LIC 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

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-20240116151820

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
	VISIT DATE: 01/18/2024

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Facility failed to provide comfortable accommodations for residents in care.
The details of the complaint alleged the facility failed to provide comfortable accommodations for residents. The complainant reported that the facility is without heat and it has been off for about a week with no plan to remedy the concern. The complainant did not provide further detailed information regarding this issue.

On 01/18/24 between 9:01 am - 10:10 am, the Department interviewed (4) out of (6) staff who claimed there have been no complaints from residents in regards to heating in private rooms or the common areas. (S1-S4) stated a Resident Council meeting was held on 01/11/24 several topics were brought up during the meeting including heating accommodations. (S1-S2) claimed that the facility received multiple donated portable electric heaters and this was discussed in the meeting and it was offered to residents in need of equipment. (S3) claimed on 01/05/24, made arrangements with a reputable heating and air condition/HVAC company who came out to inspect and replace thermostats on 01/05/24 and 01/12/24 for several resident rooms and the main dining room. (S5-S6) claimed although the thermostat was replaced and it is in working condition, there is a problem with the circulation aspect with the HVAC system not blowing warm air through air vents.

On 01/18/24 between 10:11 am - 11:37 am, the Department along with the maintenance supervisor (S3) inspected the entire facility. The inspection revealed in Arbor Hall area (2) out of (5) resident rooms did not have an operable HVAC system. In the Assisted Living area (2) out of (18) rooms did not have an operating HVAC system. Resident rooms that did not have an operable working HVAC systems were #5, #11, #165, and the main dining room. Room #165 did not have working thermostat between 01/05/24 through 1/18/24. Rooms inspected with working HVAC systems were the following: #2, #8, #17, #27, #37, #72, #140, #148, #158, #160, #221, #235, #241, #243, #253, #254, #255, #259, #268 and each room had of a comfortable range, between 68 degrees F. and 75 degrees F.

On 1/18/24 between 1:04 pm - 1:15 pm, the Department conducted a phone interview to confirm services were performed by witness #1 (W1) the heating and air condition/HVAC company on 01/05/24 and 01/12/24. (W1) verified thermostats were serviced during the service dates mentioned. Based on information gathered, there is sufficient evidence to support the allegation mentioned above.
(Evaluation Report continues LIC 999-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20240116151820

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
	VISIT DATE: 01/18/2024

NARRATIVE

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Based on observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D.

Exit interview was conducted with Julie Villanueva, Director of Resident Care and a hard copy of the report along with appeal rights.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20240116151820

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/18/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/18/2024 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator will need to replace or repair the HVAC for room #5, #11, #165 and main dining area. The licensee will provide portable heaters for rooms mentioned above until services are completed. Proof of correction must be sent to LPA by email in a video at ernand.dabuet@dss.ca.gov by 02/18/24.
	8 9 10 11 12 13 14	Based on (observation), the licensee did not comply with the section cited above. LPA identified a non-working HVAC system for room #5, #11, #165 and the main dining room.immediate This violation] which poses a potential health and safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
Type B 01/25/2024 Section Cited CCR 87468.1(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator will need to provide working portable heaters for rooms #5, #11 and main dining room. Proof of correction must be sent to LPA by email in a video at ernand.dabuet@dss.ca.gov by 01/25/24.
	8 9 10 11 12 13 14	Based on (observation), the licensee did not comply with the section cited above. LPA observed non-working HVAC system for room #5, #11, #165 and the main dining room Facility failed to provide a healthful and comfortale environment. This violation which poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 01/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2024

LIC9099 (FAS) - (06/04)

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