198204950-8-17-2024-11-AS-RORN-D8DPDG-20240822111331

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 08/17/2024
Date Signed: 08/17/2024 02:42:17 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
07/17/2024 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20240717143242

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:	08/17/2024
		UNANNOUNCED	TIME BEGAN:	09:58 AM
MET WITH:	Jessica Ponce & Beverly Malacas		TIME COMPLETED:	11:37 AM

ALLEGATION(S):

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Resident sustained unexplained bruising while in care.
Facility staf did not seek medical attention in a timely manner.
Facility staff did not allow resident visitation.

INVESTIGATION FINDINGS:

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On 08/17/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit at this facility. LPA was greeted by receptionist Jessica Ponce. LPA explained the purpose of this visit was to deliver findings for the allegations mentioned above.

The investigation consisted of the following: Investigation visits conducted on 07/19/24, 0813/24 and 08/17/24. A tour of the physical plant, interviews, and collection of records. LPA Dabuet reviewed the following documents: Facility Resident's Roster (dated: 07/19/24 & 08/13/24); Personnel Report LIC 500 (dated: 07/19/24 & 08/13/24); Resident #1 (R1's) ID and Emergency Information LIC 601(dated: 08/20/21); ) Physician Report LIC 602A (dated: 03/27/24), Preplacement Appraisal Information LIC 623 (dated: 08/17/21); Unusual Incident Report LIC 624 (dated: 06/24/24 and 06/30/24); Harbor UCLA Medical Records (dated: 06/08/24); Facility’s Body Assessment Chart (dated: 06/08/24 and 06/29/24):
Southern California Hospital Medical Records (dated: 07/03/24), SeniorDoc Medical Notes (dated: 01/31/24 -06/26/24); Medication Administration Record (dated:06/01/24-06/30/24), and other pertinent records associated with this complaint. Interviews with residents #1-#11 (R1-R11), staff #1-S4 (S1-S4), and witnesss #1-#7 (W1-W7). (Evaluation Report continues LIC 9099-C)

Unsubstantiated

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: 08/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2024

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 5

Control Number 11-AS-20240717143242

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: 08/17/2024

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: Resident sustained unexplained bruising while in care.
The details of the complaint alleged resident #1 (R1) had sustained unexplained bruising while in care at this facility. (R1) was found with suspicious bruises. The report did not provide any further details.

Investigation revealed resident #1 (R1) was admitted at Carson Senior Assisted Living (CSAL) on 08/20/21 according to Identification and Emergency Information (dated: 08/20/21). (R1) voluntarily terminated residency from (CSAL) on 06/30/24. Physician’s Report (dated: 03/27/24) and Preplacement Appraisal Information (date: 08/17/21) identified (R1) can self-care is independent and requires assistance only with dispensing medications. Records indicated (R1) had no history of skin condition or breakdown.

On 06/06/24 at 05:30 pm, (R1) was hospitalized at Harbor UCLA Medical Center (HUCLAMC) due to abdominal pain on the left side and general weakness per Incident Report LIC (dated: 06/06/24). (HUCLAMC) medical records (date: 06/08/24) revealed (R1) was treated for UTI/Pyelo with possible colitis.

On 08/13/24 between 10:10 am - 02:45 pm, the Department interviewed (4) out of (4) staff #1-#4 (S1-S4) who reported knowing a bruise on (R1’s) left hand/wrist. (S1-S4) explained they were aware of the bruised hand/wrist as it was documented by (S3) on the facility’s Body Assessment Chart (dated: 06/29/24). Written remarks indicated (R1) was showered. No scratches the body is clear and clean. Bruise on left hand indicated by (S3) on 06/29/24. (S1-S4) described (R1) is diagnosed with mental deterioration but is independent and can self-care. (R1) was not on home health or hospice care. (S1-S4) claimed that (R1) is non-ambulatory and requires assistance with assistive devices. (S1-S4) stated that (R1) was not on any required medical restraint while in care. (R1) had no accidents or falls or physical wrangles. As being independent (R1), to have minimal social interactions with other residents or staff. Interactions were defined with family representatives who came to visit or take (R1) out in the community. (S1) was being examined monthly by (R1’s) internal primary physician. SeniorDoc Medical Notes (dated: 06/26/24) verified (R1) was examined and no signs of falls, wounds, bruises, or skin breakdowns in the last six months.

(Evaluation Report continues on LIC 9099-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 11-AS-20240717143242

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: 08/17/2024

NARRATIVE

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On 08/13/24 between 10:30 am -01:16 pm, the Department interviewed (10) out of (11) residents #2-#11 (R2-R11) who are unable to corroborate this allegation. (R2-R11) claimed they have never experienced or known a resident who has sustained bodily bruises while in care.

As a result of the Department reviewing (R1) Physician Report LIC 602A (dated: 03/27/24), Preplacement
Appraisal Information LIC 623 (dated: 08/17/21); Unusual Incident Report LIC 624 (dated: 06/24/24 and 06/30/24); Harbor UCLA Medical Records (dated: 06/08/24); Facility’s Body Assessment Chart (dated: 06/08/24 and 06/29/24); Southern California Hospital Medical Records (dated: 07/03/24), SeniorDoc Medical Notes (dated: 01/31/24 -06/26/24), revealed while hospitalized, (R1) was administered Intravenous (IV) between (06/06/24-06/07/24); (R1) was on medical restraint devices between 06/30/24 – 07/07/24. Medication Administration Record (dated:06/01/24-06/30/24) revealed (R1) is on twenty (20) routine medications. Eleven (11) out of twenty (20) prescribed medications have side effects related to unusual bleeding and bruising according to the National Institute of Health (ref: NIH). Based on the gathered information, there is no evidence to support the allegation mentioned above.

Allegation #2: Facility staff did not seek medical attention in a timely manner.
The details of the complaint alleged facility staff did not seek medical attention for resident #1 (R1) in a timely manner. It was reported that (R1) required immediate medical attention and the facility staff refused to assist on 06/30/29. The report did not provide any further details.

On 08/13/24 between 10:10 am - 02:45 pm, the Department interviewed (4) out of (4) staff #1-#4 (S1-S4) who reported were aware that (R1) was sent out for further medical evaluation at a local hospital on 06/30/24. (S2) indicated family representatives came for a visit on 06/30/24 and felt a concern for (R1’s) requiring immediate 911 (EMS) medical attention. (S2) did not contact Emergency Medical Services (EMS) as (R1) was not having a life-threatening condition.

(S2) described that (R1) was not badly hurt, in danger, distressed, fainted, collapsed, persistent chest pain or difficulty breathing was the reason (S2) refused to contact 911 (EMS).

Instead, (S2) contacted a regular ambulance to transport (R1) to Southern California Hospital for further medical evaluation on 06/30/24 at 5:35 pm.

(Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 11-AS-20240717143242

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: 08/17/2024

NARRATIVE

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(S1-S4) claimed that (R1) was medically evaluated by a monthly internal medical physician. (R1) was observed daily for vital signs and monitored hourly by staff. Assessments were conducted on the body. (S1-S4) claimed that (R1) was medically evaluated by a monthly internal medical physician. (R1) was observed daily for vital signs and monitored hourly by staff. Assessments were conducted on the body. A change of condition was recorded and notified to (R1's) physician. (S1-S4) refuted the allegation the staff did not seek medical attention is untrue.

On 08/13/24 between 10:30 am -01:16 pm, the Department interviewed (10) out of (11) residents #2-#11 (R2-R11) who are unable to support this allegation. (R2-R11) claimed they are medically assisted by the facility’s internal medical physicians or their external primary physicians in a timely manner.

On 08/13/24 between 09:45 am -03:30 pm, the Department interviewed family representatives (1) out of (4) witnesses #1-#4 (W#1-W#4) who had observed a bruise and concerned for (R1) not feeling well during the visit on 06/30/24. (W1) was one of the individuals who felt that immediate medical attention was necessary. (W1) verified that an ambulance was dispatched to transport (R1) to the hospital. (W2-W4) claimed to have no issues with residents seeking medical attention as medical assistance is provided internally by the medical physicians. (W2-W4) stated they are notified by the facility staff if there’s any change in the resident’s condition.

As a result of the Department reviewing (R1) Physician Report LIC 602A (dated: 03/27/24), Preplacement
Appraisal Information LIC 623 (dated: 08/17/21); Unusual Incident Report LIC 624 (dated: 06/24/24 and 06/30/24); Facility’s Body Assessment Chart (dated: 06/08/24 and 06/29/24); SeniorDoc Medical Notes (dated: 01/31/24 -06/26/24), Medication Administration Record (dated:06/01/24-06/30/24); Change of Condition Notification Chart (dated: 06/18/24 and 06/23/24); Arbor Hall Resident 1 Hour Monitoring (dated: 06/01/24 – 06/30/24); Hospital List Char 01/01/24 - 06/30/24); Monthly Weight Record (dated: 01/04/24 – 06/05/24), revealed (R1) was monitored daily for any change of condition, and notifications were sent to (R1’s) primary care physician promptly. Based on the gathered information, there is no evidence to support the allegation mentioned above.

Allegation #3: Facility staff did not allow resident visitation.
The details of the complaint alleged the facility staff did not allow resident #1 (R1) visitors. The report indicated (R1) was denied visitors during 06/16/24 – 06/30/24.
(Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 11-AS-20240717143242

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: 08/17/2024

NARRATIVE

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On 08/13/24 between 10:10 am - 02:45 pm, the Department interviewed (4) out of (4) staff #1-#4 (S1-S4) and stated this allegation is untrue. (S1-S4) claimed that (R1) was often seen with visitors at the facility. It was common for family representatives to conduct visits outside or inside the facility. (S1) indicated there were some occasions when (R1) did not want to go outside and family did not want to visit inside and another time when (R1) did not welcome a visit and only wanted a phone conversation with family.
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On 08/13/24 between 10:30 am -01:16 pm, the Department interviewed (10) out of (11) residents #2-#11 (R2-R11) who are unable to validate this allegation. (R2-R11) said visitors are welcome, and they have no knowledge of or experience with visitors not receiving access.

On 08/13/24 between 09:45 am -03:30 pm, the Department interviewed family representatives (4) out of (4) witnesses #1-#4 (W#1-W#4) claimed they were unable to support this claim. (W1) stated (W1) was never denied visits with (R1).

The Department reviewed the facility’s Visitation Records (dated: 06/01/24 – 06/30/24), and records revealed (R1) had routine visits on 06/10/24, 06/11/24, 06/16/24, and 06/30/24. Based on the gathered information, there is no evidence to support the allegation mentioned above.

Between 08/05/24 - 08/13/24, the Department made several attempts to interview resident #1 (R1) by telephone who is now recovering at St. Francis Hospital. (R1) was unwilling and unable to communicate in full conversation.

Between 08/06/24 – 08/14/24, the Department attempted to interview family representatives of (R1) witnesses #5-#7 (W5-W7) by telephone who were unavailable for statements.

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 violations, did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted with Beverly Malacas , and copies of the reports were provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 08/17/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/17/2024

LIC9099 (FAS) - (06/04)

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