198204950-5-15-2024-11-AS-MVAO-D5VQWJ-20240603123202

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 05/15/2024
Date Signed: 05/15/2024 04:16:34 PM

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
05/10/2024 and conducted by Evaluator Jose Calderon

COMPLAINT CONTROL NUMBER: 11-AS-20240510162647

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: 170	DATE:	05/15/2024
		UNANNOUNCED	TIME BEGAN:	09:51 AM
MET WITH:	ADMINISTRATOR GINGER ENRIQUEZ		TIME COMPLETED:	04:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff neglected resident
Staff withheld resident's medication
Staff did not respond to resident's call assistance button in a timely manner

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 05/15/2024 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Carson Senior Assisted Living facility and was greeted by Administrator Ginger Enriquez (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegations.

The investigation consisted of the following: LPA Calderon interviewed Administrator A1, Staff S1-S3, Resident R1-R10, Witness W1. These interviews were conducted on 05/15/2024. LPA Calderon obtained and reviewed the following: Physician Report (dated 3/21/2024), Needs and Service plan (dated 05/15/2024), incident reports (date 05/10/2024 and 05/11/2024), Medical administration records (MAR) (date April, May 2024), preplacement appraisal (date 03/27/2024), call button log (date 04/10/2024) for R1.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

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-20240510162647

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: 05/15/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Regarding Allegation #1: Staff neglected resident.

This complaint alleged that staff neglected R1. A1 states that no staff would ever neglect a resident in care. A1 states no staff would ever refuse to call 911. LPA Calderon interviewed S1-S3. 3 out of 3 staff state that they would never neglect a resident in care. 3 out of 3 staff state that staff member would not refuse to call 911 if needed or have words with a resident in care. LPA Calderon interviewed R1-R10. R1 states that staff refused to call 911 for R1 and staff called R1 names. R1 states that staff have neglected R1 care. 9 out of 10 resident states that staff do not neglect their care and they have no issues with staff. W1 states that W1 was aware of R1 calling 911 and staff refused to call 911. W1 states that unknown staff called R1 words that were hurtful. On 05/15/2024 LPA Calderon reviewed the following: Reviewed the Physician report (date 03/21/2024), R1 has health issues. Reviewed incident report (date 05/10/2024) R1 was having chest pain and staff called 911.

Regarding Allegation #2: Staff withheld residents’ medication.

This complaint alleged that staff withheld medication from R1. A1 states that at no time would any staff member refuse or withhold R1 or any medication from a resident in care. A1 states that accurate records are kept for any resident that takes medications. 3 out of 3 staff state that no staff would refuse or withhold any medication for R1 or any resident in care. 3 out of 3 staff state that accurate records are kept for each resident that takes medications.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 11-AS-20240510162647

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: 05/15/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA Calderon interviewed R1-R10. R1states that staff refused to give medication to R1. 9 out of 10 residents state that no staff member has refused or withhold any medication. LPA interviewed W1 who states that facility staff refused to give medication to R1. LPA Calderon reviewed the MAR for (April, May 2024) for R1. LPA Could not find any errors for R1 MAR.

Regarding Allegation #3: Staff did not respond to resident’s call assistance button in a timely manner.

This complaint alleged that staff did not respond to R1 call button in a timely manner. A1 states that on average it takes 5 to 10 minutes for staff to answer resident call button. A1 states that every time a resident presses the call button the front desk answers and staff are sent to the resident’s room. 3 out of 3 staff state that it takes 5 to 10 minutes for staff to respond to a call button push. R1 states that R1 has pressed the call button and no staff responds. 9 out of 10 residents state that it takes 5 minutes for staff to respond to a call button. W1 states that W1 has noted no staff has responded to R1 call button push. LPA Calderon toured the facility and LPA pushed the call button for rooms 163, 273, 274 and 275. On average it took 5 minutes for staff to show up to the resident room and every time the call button was pushed the front desk answered. LPA Calderon noted 3 staff answered the call.

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20240510162647

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: 05/15/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on interviews, observations and supporting documentation, the preponderance of evidence standard has NOT been met; therefore, the allegation of “staff neglected resident” “staff withheld residents’ medication” “staff did not respond to resident’s call assistance button in a timely manner” is found to be UNSUBSTANTIATED.

An exit interview was conducted, and a copy of the Complaint Report were provided to the Administrator Ginger Enriquez (A1).

SUPERVISOR'S NAME: Ulysses Coronel	TELEPHONE: (323) 400-7397
LICENSING EVALUATOR NAME: Jose Calderon	TELEPHONE: (323) 213-1153
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4