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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204950
Report Date: 11/18/2024
Date Signed: 11/18/2024 11:12:27 AM

Document Has Been Signed on 11/18/2024 11:12 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
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:CARSON SENIOR ASSISTED LIVINGFACILITY NUMBER:
198204950
ADMINISTRATOR/
DIRECTOR:		SHOLOM GOLDMANFACILITY TYPE:
740
ADDRESS:345 EAST CARSON STREETTELEPHONE:
(310) 830-4010
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 230CENSUS: 168DATE:
11/18/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:07 AM
MET WITH:Gabby EusebioTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
NARRATIVE
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On 11/18/24, Licensing Program Analyst (LPA) Ernand Dabuet initiated an unannounced Case Management visit at this facility. LPA met with Resident Care Coordinator RCC #1 (RCC#1) Gabby Eusebio. LPA explained the purpose of this visit is about an incident on 08/05/24 associated with resident #1 (R1) and staff #1 (S1) in the Arbor Hall Memory Care Unit.

El Segundo Regional Office received an LIC 624 Incident Report (dated: 11/11/24). Information revealed on 11/05/24, approximately 01:00 am, (R1) from Arbor Hall was discovered not in the room or any part of the facility. The care staff on duty search for (R1) outside grounds of the facility but did not find (R1). The care staff contacted the Carson Sheriff's Department.

On 11/12/24, (LPA) Dabuet followed up with Administrator and was informed not having any notion how (R1) was able to leave the Arbor Hall (memory care unit) when exit doors are controlled egress locking system. The facility is also has surveillance cameras in the common areas to monitor daily activities. The Resident Care Coordinator contact local emergency rooms in search for (R1). Later late afternoon on 11/12/24, (R1) was found by Fullerton Police Department and was taken to Anaheim Global Hospital for observation.

Interviews with the Administrator and Resident Care Coordinator verified (R1) eloped from the facility without care supervision. A review of (R1's) Physicians Report LIC 602A (dated: 03/31/23) revealed that (R1) has wandering behavior and is not able to leave the facility unassisted.

Based on observations, interviews, and record reviews, the preponderance of evidence standard has been met, "NEGLECT and LACK OF CARE AND SUPERVISION". California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D.

Exit interview was conducted with Gabby Eusebio, Resident Care Coordinator and a hard copy of the report along with appeal rights.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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 11/18/2024 11:12 AM - It Cannot Be Edited


Created By: Ernand Dabuet On 11/18/2024 at 10:42 AM
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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CARSON SENIOR ASSISTED LIVING
FACILITY NUMBER: 198204950

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/19/2024
Section Cited
CCR
87705(b)(2)

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87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including:.(2) Safety measures to address behaviors such as wandering, aggressive behavior and ingestion of toxic materials.
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Licensee agrees that a Plan of Correction will be submitted to CCLD by 11/19/24, Administrator agreed that Arbor Hall staff will be advised to be on "high alert" meaning being more vigilant in monitoring all access exit door and windows while a Plan of Correction is developed by POC date 11/19/21 to the licensing office.
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This requirement was not met as evidence by:
Based on LPA interviews conducted and record reviews, the Licensee failed to ensure to address R1's history of wandering behavior and went missing, while unsupervised by facility staff. This violation poses an immediate health and safety risk to residents in care.
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Type B
12/02/2024
Section Cited
CCR87466

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87466 Observation of Resident -The licensee to ensure that residents are regularly observed for changes in physical, mental, emotional, and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.
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Licensee shall have a written plan to ensure that in addition to the resident's needs and services plan a specific plan is drafted for each resident's change in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. The plan must be submitted by POC date 12/02/24 to the licensing office.
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Based on LPA interviews conducted and record reviews, the Licensee was aware of of R1's history of wandering behavior failed to ensure proper supervision was in in place. This violation 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:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 11/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2024


LIC809 (FAS) - (06/04)
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