198204950-8-13-2024-11-AS-EMAZ-D9TSS5-20241007140723

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 08/13/2024
Date Signed: 08/13/2024 04:02:38 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
08/05/2024 and conducted by Evaluator Alfonso Iniguez

COMPLAINT CONTROL NUMBER: 11-AS-20240805102936

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:	08/13/2024
		UNANNOUNCED	TIME BEGAN:	09:14 AM
MET WITH:	Ginger Enriquez-Administrator		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff withheld residents' medication, which resulted in their hospitalization

INVESTIGATION FINDINGS:

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On 8/13/2023 LPA Alfonso Iniguez conducted an unannounced complaint visit. LPA Iniguez met with Ginger Enriquez /Administrator. LPA explained the purpose of this visit.

Investigation Consisted of: LPA conducted the following interviews: Administrator Interview(A#1), Resident’s interviews (R#1-R#9) and Staff Interviews (S#1-S#4). LPA obtained and reviewed the following documents: Resident’s roster, Personnel roster, (R#1-R#5) Identification and Emergency Information, (R#1-R#5) Admissions agreements, (R#1-R#5) Physicians Report for Residential Care Facilities for the Elderly, (R#1-R#5) Needs and Services Plan, (R#1-R#5) Medication Administration Record (MAR) from January 2024-June 2024 and (R#1)’s hospital records dated 2/17/24 and 3/13/24.

Evaluation Report continues LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

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-20240805102936

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: 08/13/2024

NARRATIVE

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Investigation Revealed the Following:

Allegation: Staff withheld residents' medication, which resulted in their hospitalization.

The details of the complaint alleged that facility staff withheld resident’s medications, which resulted in their hospitalization.

During the records review, LPA Iniguez reviewed (R#1)’s Medication Administration Records-MAR from August 2024; LPA did not find discrepancies on the logs, and the facility documented every time (R#1) got their medications. In addition, LPA reviewed (R#2-R#4)’s Medication Administration Records-MAR from January to August 2024; LPA did not find discrepancies in the logs. Furthermore, LPA reviewed (R#1)’s hospitalization records dated 2/17/24 and 3/13/24; the medical records did not state that hospitalization was due to medication management but instead was another physical illness that (R#1) was diagnosed.

During an interview with the Administrator (A#1), she stated that residents are getting their medications as prescribed by their physician and that the facility has never withheld residents’ medications. Also, (A#1) stated that no resident missed their medicines due to staff negligence.

During interviews with residents (R#1-R#10), (10) out of (10) residents stated that they took prescribed medications and that they have never missed a dose due to staff negligence. Also, (10) out of (10) residents stated that the facility has never withheld their medications.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20240805102936

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: 08/13/2024

NARRATIVE

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During interviews with staff (S#1-S#3), (3) out (3) facility staff stated that residents are getting their medications as prescribed by their physician and that the facility has never withheld residents’ medications. Also, (3) out of (3) facility staff stated that no resident has ever missed their medicines due to staff negligence.

During this investigation, LPA found did not find sufficient evident to support the above-mentioned allegations.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

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.

An exit interview was conducted, and a copy of the Complaint Report was given to Ginger Enriquez /Administrator.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Alfonso Iniguez	TELEPHONE: 323-981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2024

LIC9099 (FAS) - (06/04)

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