198204950-10-21-2024-11-AS-JHAD-DAS2WY-20241106164620

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 10/21/2024
Date Signed: 10/21/2024 03:32:14 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
10/14/2024 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20241014093112

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: 171	DATE:	10/21/2024
		UNANNOUNCED	TIME BEGAN:	09:07 AM
MET WITH:	Ginger Enriquez		TIME COMPLETED:	03:47 PM

ALLEGATION(S):

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Lack of supervision resulting in physical altercations between residents.

INVESTIGATION FINDINGS:

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On 10/21/24, the Community Care Licensing (CCL) associate made an unannounced visit to this facility and was greeted by Administrator (S1: Ginger Enriquez). The purpose for today’s visit is to gather information pertaining to the above-mentioned allegation.

The investigation consisted of the following: A health and safety inspecton, interviews, and collection of records. (CCL) associate reviewed the following documents: Facility Resident's Roster (dated: 10/21/24); Personnel Report LIC 500 (dated: 10/21/24); Resident #1 and #2 (R1-R2) Resident Face Sheet ID and Emergency Information LIC 601 (dated: 10/24/23); Physician Report LIC 602A (dated: 07/14/23 & 06/28/24), Preplacement Appraisal Information LIC 623 (dated: 10/23/23); Admissions Agreement LIC604A (dated: 07/23/24 & 10/24/23); and other pertinent records in association with this allegaitoin. Interviews with residents #1-#10 (R1-R10), staff #1-S3 (S1-S3), and witnesss #1 (W1).
(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: 10/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024

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 3

Control Number 11-AS-20241014093112

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: 10/21/2024

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Staff did not prevent residents from engaging in physical altercation.
The details of this complaint alleged that due to a lack of facility supervision residents engaged in an altercation. It is reported that Resident #1 (R1) is being repeatedly hit on the back of the head by Resident #2 (R2) while both are in the dining room. The administrator has been informed of the incidents and (R1) has been ignored. Further details indicated that there have been no injuries.

On 03/21/24 between 09:50 am – 12:20 pm, the Department interviewed (10) out (10) resident #1 - #10 were unable to corroborate the allegation. Eight (8) out (10) residents #2 - #10 (R2-R10) revealed themselves unable to verify these incidents, and no one observed any act of aggression on a resident. (R2-R10) stated that staff are responsive and will not tolerate inappropriate behavior from residents.

(R1) was interviewed and was unwilling to provide a statement. (R1) claimed there is no issue with (R2). (R2) was interviewed and stated engagements with (R1) are friendly. (R2) described an incident last week where (R1) inappropriately addressed other residents in the dining hall. (R2) had enough of (R1’s) behavior and confronted (R1) and made (R1) aware of the improper verbal actions. (R2) claimed there was no physical altercation and that the administrator consulted (R1) and (R2) about the incident. (R2) indicated and (R1) are in kind terms.

On 03/21/24 between 10:10 am – 11:20 am, the Department interviewed (3) out of (3) staff #1-#3 (S1-S3) who denied an altercation between (R1) and (R2). (S1) claimed last week, (S1) was made aware of verbal exchanges between (R1) and (R2). Both residents were consulted for their actions and given a verbal warning. (S1-S3) have experienced or witnessed (R1) have made offensive comments about other residents. (R1) has been consulted repeatedly and informed that this behavior is unacceptable according to (S1-S3).

On 03/21/24 between 11:04 am – 11:22 am, the Department interviewed a family representative of (R1) witness #1 (W1). (W1) claimed to be unaware of any incident involving (R1) and (R2). (W1) described (R1) as being a strong head, and if (R1) did not want to volunteer a statement or stated to disregard it, it is mostly likely that (R1) was at fault.
(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: 10/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20241014093112

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: 10/21/2024

NARRATIVE

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(W1) claimed that (R1) does not have a pattern of engaging in improper verbal attacks on others, unless (R1) has been provoked. (W1) verified that the administrator has reached out to (W1) for (R1) insensitive comments towards other residents. Based on the gathered information, there is no evidence to support the allegations mentioned above.

Based on information collected, an inspection of the facility, observation, and interviews conducted, an analysis of records reviewed, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted with Ginger Enriquez, 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: 10/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2024

LIC9099 (FAS) - (06/04)

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