198204950-12-4-2023-11-AS-JHAD-CY7QYM-20231204113518

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 12/01/2023
Date Signed: 12/04/2023 07:14:51 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/17/2021 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210317104047

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: 162	DATE:	12/01/2023
		UNANNOUNCED	TIME BEGAN:	08:10 AM
MET WITH:	Ginger Enriquez		TIME COMPLETED:	04:59 PM

ALLEGATION(S):

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Facility neglect resulting in resident developing infection.
Resident fell while in care.

INVESTIGATION FINDINGS:

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On 12/01/23, Licensing Program Analyst (LPA) Ernand Dabuet subsequent an unannounced complaint visit at this facility. LPA met with Administrator Ginger Enriquez , and explained the purpose of today's visit is to to condcut staff interviews and deliver findings for the the allegations mentioned above.

The investigation consisted of the following: Interviews with staff #1-#5, residents #1-#10, witnessess #1-#5, review of staff roster, resident roster, (R1's) service records, medical records, Incontinent 2-hour check logs, and other pertinent documents associated to this complaint. A tour of the facility on 03/18/21, 07/30/21, 09/27/23, and 12/01/23.

(Evaluation Report continues on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210317104047

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
	VISIT DATE: 12/01/2023

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Facility neglect resulting in resident developing infection.
The details of the complaint alleged staff neglected resident #1 (R1's) care, resulting in an infection. The complainant reported that (R1) has not had a wellness care checkup since 2018 which may have caused (R1) to have an inactive Hepatitis B. The complainant did not provide any further information.

(R1) was at this facility on 08/27/18 according to (R1’s) Identification and Emergency Information LIC 601 (dated: 08/27/18) (R1) did not have a legal guardian, power of attorney, conservator, or family listed. (R1) was admitted with no history of hepatitis infection. Medical lab test results (date:8/29/18 and 08/14/19) presented no hepatitis. (R1) continued medical checkups with the in-house physicians. Records indicate physician visits as follows: 09/20/18,11/19/18, 12/12/18, 08/28/19, 02/19/20, 12/17/19, 08/13/20, 08/17/20, 09/03/20, and 09/13/20. Psychiatric Assessments were conducted monthly from 12/12/18 through 12/31/20.
Medical records for (R1) revealed on 09/03/20 reportedly, the lab work unable to be drawn due to the insurance card not being verified by the lab company. Medical records for (R1) (dated: 04/13/22) enclose a history of chronic hepatitis B, chronic hepatitis C, alcoholism, drug abuse, and TB infection. According to (ref: Mayo Clinic), the Hepatitis virus is passed from person to person through blood, semen, or other body fluids, and unsafe injection or exposure to sharp instruments. The Physician's Report LIC 602 for (R1) states that (R1) is unable to leave the facility unassisted nor had wandering behavior. ( R1)'s medication remained constant during his residency at the facility, and no needle injections were required according to his Medication Administration Records.

On 09/27/23, interviews conducted between 10:00 am and 3:11 pm with (9) out (9) residents #2-#10 (R2-R10) claimed they were all healthy and had not acquired any infections due to lack of care. (R2-R10) reported medical assistance is available from their primary physician or the in-house primary physicians and is always accessible.

On 09/27/23, interviews conducted between 10:37 am and 12:43 pm with (5) out (5) family representatives witness #1-#5 (W1-W5) stating no concerns for the health care for the residents at this facility.

(Evaluation Report continues on LIC 9099-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210317104047

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
	VISIT DATE: 12/01/2023

NARRATIVE

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Several attempts to interview (R1) on 09/27/23 and 11/27/23 were unsuccessful. (R1’s) health condition prevented (R1) from carrying full conversations.

On 12/01/23, in interviews conducted between 11:00 am and 1:00 pm (5) out of (5) staff # 1- #5 (S1-S5) did not know how (R1) may have been exposed to an infection. (S3-S5) claimed that (R1) did not engage with others and was not intimate with any residents at the facility. Based on the information provided, it is unclear whether (R1) was exposed to or contracted the infection while in care at the facility. Therefore, based on all the information obtained during the investigation, there is no evidence to corroborate the allegation mentioned above.

Allegation #2: Resident fell while in care.
The complaint alleged resident #1 (R1) fell due to staff negligence while in care. The complainant (R1) fell off the bed and incurred bruises on the left side of the face. There was no further information provided by the complainant on this matter.

A review of an incident report (dated: 03/01/21) revealed (R1) slid out of the wheelchair at 11:00 am on 03/01/21 while watching television in the activity room. The unwitnessed incident indicated (R1) sustained a minor bump on the upper left cheek and an ice pack was applied. There was no indication of an open wound. According to (R1’s) Physician’s Report LIC 602A, (R1), functional capabilities use a walker and a wheelchair unassisted (dated: 01/17/20). There is no indication in any of (R1’s) service records that (R1) was considered a fall risk and required constant supervision nor presented a history of falls. The facility notified the primary physician and Community Care Licensing (CCL) of this incident. A review of (R1) medications listed (R1) on Questiapine 200mg, Cetizine 10 mg, Aripirazole 10mg, and Norvasc 10mg. These medications all have side effects of simple unusual bleeding or bruising according to Mayo Clinic (ref. Mayo Clinic.org).

On 09/27/23, interviews were conducted between 10:00 am and 3:11 pm with (9) out (9) residents #2-#10 (R2-R10) all confirmed to have no issue with accidents or falls while in care. (R2-R10) reported the care and supervision were adequate and felt safe while at the facility.

(Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 11-AS-20210317104047

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
	VISIT DATE: 12/01/2023

NARRATIVE

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An interview on 12/01/23 at 9:30 am with staff # (S2) confirmed to have had knowledge of the incident on 03/01/21 documented the necessary information, and later contacted the proper authorities of the incident. (S2) at the time of the incident, (R1) did not have an open wound nor showed signs of bruises. (S2) reported that (R1) is non-ambulatory and can get around with the help of a walker or wheelchair. (S2) stated (R1) only needed assistance transferring in and out of bed. Interviews conducted on 12/01/23 at 11:00 am – 1:00 pm with (4) out (4) staff #1, #3 - #5 (S1-S5) confirmed that (R1) was not a fall risk and did not have a history of falls at the facility.

A review of (R1’s) Incontinent 2-hour check logs revealed (R1) was being supervised every 2 hours daily by staff. Several attempts to interview (R1) on 09/27/23 and 11/27/23 were unsuccessful. (R1’s) health condition prevented (R1) from carrying on full conversations. Therefore, based on all the information obtained during the investigation, there is no evidence to corroborate the allegation mentioned above.

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 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 Ginger Enriquez, and copies of the reports were provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

LIC9099 (FAS) - (06/04)

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