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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204950
Report Date: 09/06/2024
Date Signed: 09/06/2024 06:51:38 PM


Document Has Been Signed on 09/06/2024 06:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 LIVINGFACILITY NUMBER:
198204950
ADMINISTRATOR:SHOLOM GOLDMANFACILITY TYPE:
740
ADDRESS:345 EAST CARSON STREETTELEPHONE:
(310) 830-4010
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY:230CENSUS: 164DATE:
09/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:37 PM
MET WITH:Gabriela Eusebio & Ginger Enriquez TIME COMPLETED:
03:28 PM
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On 09/06/24, Licensing Program Analyst (LPA) Ernand Dabuet initiated an unannounced Case Management visit at this facility. LPA met with Resident Care Coordinator RCC #1 (RCC#1) Gabby Eusebio and Assistant Administrator #1 (A#1) Ginger Enriquez. LPA explained the purpose of this visit is about an incident on 08/05/24 associated with resident #1 (R1) and staff #1 (S1) in the Arbor Hall Memory Care Unit.

El Segundo Regional Office received an LIC 624 Incident Report (dated: 08/12/24). Information revealed on 08/05/24, approximately around noon, (R1) was in the dining room for lunch grabbed a Lorazepam medication from another resident sitting next to (R1), and swallowed it. On the evening of 08/05/24, (R1) had an unwitnessed fall in (R1’s) room and sustained a laceration behind the right ear.

On 09/06/24, an interview with Resident Care Coordinator (RCC#1) and Assistant Administrator (A#1) verified the incident and communicated that it was the negligence of (S1) to leave medications unattended. (S1) failed to supervise and allowed for (R1) to have access to medications that were not prescribed to (R1). (RCC#1) and (A1#1) both claimed that (S1) withheld information from management and did not report the incident immediately to them. The hospice team examined (R1) and assessed the laceration after (S1) reported it to (R1's) hospice.

Interviews with the CV Hospice nurse and (R1’s) authorized representatives verified the incident with the medication error may have been attributed to the unwitnessed fall with injuries. However, medication records for (R1) revealed (R1) is prescribed Lorazepam as a (PRN). Interviews were not available for (R1) and (S1). (R1) had voluntarily terminated residency on 08/31/24, and (S1) was terminated from employment.

(Evaluation Report continues on LIC 809-C)
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/06/2024
NARRATIVE
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Based on observations, interviews, and record reviews, a preponderance of evidence standard has been met. (S1) failed to carry out the responsibilities and duties of a caregiver who failed to store medications and inaccessible to residents in care. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 809-D.

An exit interview was conducted with Ginger Enriquez, Assistant Administrator, and a hard copy of the report along with appeal rights.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/06/2024 06:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/07/2024
Section Cited
CCR
87705(f)(2)

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87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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Licensee/Administrator agreed to comply with and review Title 22 Regulation, Section “Care of Persons with Dementia" and will ensure all staff complete Medication Training. A sign-in sheet with all staff who completed the training is due by POC date to LPA Dabuet via email: ernand.dabuet@dss.ca.gov
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This requirement is not met as evidenced by:
Based on interviews and record review, (S1) failed to carry out the duties and responsiblites and left medication unattended and accessible to (R1) with dementia. This violation poses an immediate health, safety or personal rights risk to persons in care.
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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 HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2024
LIC809 (FAS) - (06/04)
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