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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204950
Report Date: 07/23/2021
Date Signed: 07/26/2021 10:57:03 AM

Document Has Been Signed on 07/26/2021 10:57 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
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: 174DATE:
07/23/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Ginger EnriquezTIME COMPLETED:
04:14 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ulysses Coronel initiated a Case Management - Deficiencies visit to document deficiencies observed during investigation of the complaint with complaint control number 11-AS-20210618162058. LPA met with administrator Ginger Enriquez and the purpose of the visit was explained.

On 11/05/2020 R1’s Physician’s Report indicate that R1 is not able to administer own injections and not able to perform own glucose testing. On 12/20/2020 R1’s Appraisal Needs, and Services Plan indicate that R1 is confused and forgetful at times. On 07/16/2021 reviews of R1's medical administration record indicate that R1 administers own injections.

An exit interview was conducted, plan of corrections were developed with administrator. A copy of this report and appeals rights were provided to Ginger Enriquez, the administrator.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2021
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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Document Has Been Signed on 07/26/2021 10:57 AM - It Cannot Be Edited


Created By: Ulysses Coronel On 07/23/2021 at 03:07 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CARSON SENIOR ASSISTED LIVING
FACILITY NUMBER: 198204950

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/13/2021
Section Cited
CCR
87705(c)(5)(A)

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87705(c)(5)(A) Care of Persons with Dementia. Licensees... When any medical assessment, appraisal, or observation indicates that the resident’s dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident. This requirement was not met as evidenced by
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Administrator will develop a services plan for meeting R1's Dementia needs. Proof of corrections will be submitted on POC due date.
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Based on interviews and records reviews the licensee failed to ensure that changes were made in the care and supervision when residents dementia needs have changed, R1 who was observed forgetful and confused was allowed to self administer Insulin injections which poses a potential health and safety risk to residents 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 Hammond
LICENSING EVALUATOR NAME:Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2021


LIC809 (FAS) - (06/04)
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