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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 04/18/2024
Date Signed: 04/18/2024 11:29:27 AM

Unsubstantiated


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
04/11/2024 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240411145833
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: 172DATE:
04/18/2024
UNANNOUNCEDTIME BEGAN:
08:01 AM
MET WITH:Ginger EnriquezTIME COMPLETED:
11:32 AM
ALLEGATION(S):
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Illegal Eviction
INVESTIGATION FINDINGS:
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On 04/18/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit at this facility. LPA was greeted by the Administrator Ginger Enriquez. LPA explained the purpose of this visit was 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 resident #1-#2 (R1-R2), administrator #1 (A1), staff #1 (S1) and witness #1-(W1-W2). Service records for resident #1 (R1), Physicians Report, Admission Agreement, Appraisal/Needs and Service Plan, and other pertinent documents associated with this complaint. A tour of the facility and (R1's) room.

(Evaluation Report continues LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
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 3
Control Number 11-AS-20240411145833
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: 04/18/2024
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Illegal Eviction.

A review of (R1’s) Identification and Emergency Information LIC 601 (dated: 11/22/23), (R1) was admitted to Carson Senior Assisted Living on 11/22/23. According to facility Incident Reports LIC 624 (dated: 03/04/24 – 03/06/24), (R1) had three consecutive incidents involving staff on 03/04/24, 03/05/24, and 03/06/24, which led to (R1) being admitted at Harbor UCLA Medical Center, Exodus Recovery, Inc. Urgent Care Center and Southern California Hospital at Culver City.

On 04/15/24, between 12:07 pm – and 12:57 pm the Department interviewed (2) out of (2) administrator #1 (A1) and staff #1 both denied the allegation. (A1) stated that she never issued a formal eviction notice to (R1). (A1) claimed (R1) remained a resident and that no personal belongings were removed from (R1’s) room. (A1 and S1) stated that (R1) has not been denied access inside the facility and continues to benefit from services provided by the facility. (A1) stated (R1) has received consultation on house rules. The administrator stated (C1) had three consecutive incidents on 03/04/24, 03/05/24, and 03/06/24, which would have warrant a formal eviction notice.

(A1) added that if a formal eviction was implemented, (A1) would adhere to Title 22 regulations and notify Community Care Licensing in writing. In an interview with (S1), who was the staff involved in the incident on 03/06/24 with (R1), contacted 9-1-1. (S1) reported the Carson Sheriff's Department arrived at the facility and detained (R1). Later the Carson Sheriff escorted (R1) to Harbor UCLA Medical Center on 03/06/24 for medical evaluation. (A1) stated it was (R1’s) Laterman Petris Short Act (LPS) Social Worker and California State Public Guardian/Conservator who notified (R1) was transferred to Southern California Hospital at Culver City for further observation. (A1) claimed that a telephone discussion with (LPS) and the Public Guardian/Conservator about the possibility of relocating (R1) to another facility as (R1’s) needs and services may require a higher level of care. However, there have been no updates or fruition on the matter.

On 04/15/24, between 01:12 pm – 01:22 pm, the Department conducted a telephone interview with (R1) who does not recall incidents that happened on 03/04/05, 03/05/25, and 03/06/24. (R1) claimed that no one at the facility has notified (R1) of an eviction and that no one has served (R1) with formal eviction in writing.

(Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20240411145833
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: 04/18/2024
NARRATIVE
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On 04/15/24, between 01:34 pm – 01:44 pm, the Department interviewed resident #2 (R2) a former roommate of (R1). (R2) claimed there is a reason that they are no longer roommates as (R1) does not adhere to the house rules. (R2) claimed not to have any knowledge of an eviction for (R1) but (R2) added it would not be a surprised as (R1) would be evicted, as (R1) does not follow the facility rules.

On 04/15/24 at 01:23 pm – 01:33 pm, the Department interviewed California State Public Guardian/Conservator witness #1 (W1) for resident #1. (W1) confirmed that a conversation with (A1) discussed the possibility of transferring (R1) to another facility due to the incidents that occurred in March 2024 and that (R1) may require a higher level of care. (W1) stated there were no agreements of evicting the (R1) that came out of the discussion on 03/06/24.

On 04/18/24 at 08:01 am – 08:23 am the Department interviewed (LPS) Social Worker witness #2 (W2) for resident #1. (W2) verified that a discussion of (R1) is being observed at Southern California Hospital at Culver City and the possibility of (R1) needing a higher level of care. (W2) claimed there were no arrangements for evicting the (R1) that came out of the discussion on 03/06/24.

During the investigation on 04/15/24 and 04/18/24, the Department observed (R1) is included in the resident roster. The Department observed (R1's) personal possessions in (R1's) room.

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

Although the allegation may have happened or is valid, there is not enough preponderance of evidence to evidence the alleged allegation is valid did or did not occur, therefore the allegation is "Unsubstantiated".

An exit interview was conducted with Ginger Enriquez, and a hard copy was provided.

SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 04/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3