198204950-8-13-2024-11-AS-EMAZ-DATS5S-20241108123449

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 08/13/2024
Date Signed: 08/13/2024 04:00:25 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
07/18/2024 and conducted by Evaluator Alfonso Iniguez

COMPLAINT CONTROL NUMBER: 11-AS-20240718111100

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 do not allow resident to manage own funds
Staff did not safeguard resident's finances

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#10) 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 August 2024 copy of Social Security Administration Retirement, Survivor and Disability Insurance dated 8/4/2024.

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)

Page: 1 of 5

Control Number 11-AS-20240718111100

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 do not allow resident to manage own funds.

The details of the complaint alleged that facility staff did not allow resident to manage their own funds.

During the records review, LPA Iniguez reviewed (R#1)’s Physician’s Report for Residential Care Facilities for the Elderly (RCFE) or LIC 602A. It is written that (R#1) is not confused or disoriented, but the physician completing the form marked “A084” as an extra notation in this field. Also, (R#1) can manage its cash resources. In addition, LPA reviewed (R#1)’s Preplacement Appraisal Information or LIC 603, and it is written that (R#1) is confused. Furthermore, LPA reviewed a copy of the Social Security Administration Retirement, Survivor and Disability Insurance dated 8/4/2024; it is written that Social Security Has chosen the facility Carson Retirement Center as the representative payee for (R#1)’s monthly check. Also, the letter states that as the payee for (R#1), the facility needs to keep track of how they will use the money they send for (R#1); each year, they will ask to report on how they used it. Furthermore, LPA reviewed (R#1)’s admissions agreement. (R#1) was admitted to the facility on 2/19/2020. However, during the interview with LPA Iniguez, (R#1) stated that all these allegations happened eight years ago, back in 2016, and (R#1) was not living at that time at this facility.

During an Interview with the Administrator (A#1), she stated that (R#1) used to manage their funds until Social Security deemed that the facility would manage (R#1) 's funds starting 8/4/23. The facility became (R#1) 's payee from Social Security Administration Retirement, Survivors, and Disability Insurance Services, and since the facility manages some residents' finances, they do have a Surety Bond. Also, (A#1) stated that she has not known of heard about (R#1)’s wallet being stolen or (R#1) getting physically attacked while living at the facility.

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)

Page: 2 of 5

Control Number 11-AS-20240718111100

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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This report serves as an amendment to clarify finding. It does not supersedes the complaint investigation findings reflected on report created 8/13/24

During an interview with resident 1 (R#1), they stated that they had been here for eight years; the facility administrator manages their finances, but the administrator is taking their money from their bank account. LPA asked (R#1) how they knew the administrator was taking money from them; they said the bank told them the administrator had taken their money. LPA asked (R#1) if they had something in writing about that. (R#1) said no, all my money is under the administrators.

During interviews with residents (R#2-R#10), (5) out of (10) residents stated that the facility manages their finances and P&I; those funds are from Social Security. Also, (3) out of (10) residents indicated that their families and conservator manage their finances, and (2) out of (10) residents manage their finances. In addition, (9) out of (10) residents stated that they fee safe living here.

During interviews with staff (S#1-S#3), (3) out (3) facility staff stated that they do not know if (A#1) has taken money from (R#1)’s bank account and they don’t think (A#1) is not allowing (R#1) to manage their finances, they said Social Security made the facility the payee for (R#1)’s monthly check. Also, (3) out of (3) facility staff stated that they had not heard about (R#1)’s wallet being stolen or (R#1) getting physically attacked while living at the facility.

Allegation: Staff did not safeguard resident's finances.

The details of the complaint alleged that facility staff did not safeguard resident’s finances.

During the records review, LPA Iniguez reviewed (R#1)’s Record of the Client’s/Resident’s Safeguarded Cash Resources or LIC 405 from August 2023 until August 2024; the ledger shows the amount (R#1) gets from Social Security to pay for their rent. In addition, the facility keeps a record of the leftover money as P&I for (R#1) every time they give some (R#1) signs for it. Furthermore, LPA reviewed (R#1)’s admissions agreement. (R#1) was admitted to the facility on 2/19/2020. However, during the interview with LPA Iniguez, (R#1) stated that all these allegations happened eight years ago, back in 2016, and (R#1) was not living at that time at this facility.

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)

Page: 3 of 5

Control Number 11-AS-20240718111100

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 an Interview with the Administrator (A#1), she stated that the facility safeguards (R#1) 's finances and the other residents; the facility uses the Record of the Client's/Resident's Safeguarded Cash Resources or LIC 405 to record the resident's finances. In addition, (A#1) stated that she has not taken money from (R#1) 's bank account, and (R#1) has not had their wallet stolen or been physically attacked while living here.

During an interview with resident 1 (R#1), they stated that they had been here for eight years; the facility administrator manages their finances, but the administrator is taking their money from their bank account. LPA asked (R#1) how they knew the administrator was taking money from them; they said the bank told them the administrator had taken their money. LPA asked (R#1) if they had something in writing about that. (R#1) said no, all my money is under the administrators. LPA asked (R#1) if they felt safe living here, and they stated that no, I got hit five times in the face. Also, (R#1) stated that someone stole their wallet eight years ago.

During interviews with residents (R#2-R#10), (5) out of (10) residents stated that the facility manages their finances and P&I; they feel the facility does a good job. Also, (3) out of (10) residents indicated that their families and conservator manage their finances, and (2) out of (10) residents manage their finances.

During interviews with staff (S#1-S#3), (3) out (3) facility staff stated that the facility keeps a ledger or a Record of the Client’s/Resident’s Safeguarded Cash Resources or LIC 405 for the residents that received Social Security benefits.

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)

Page: 4 of 5

Control Number 11-AS-20240718111100

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 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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