198204950-4-3-2024-11-AS-EMAZ-D45MX5-20240408095920

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 04/03/2024
Date Signed: 04/03/2024 03:41:15 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/27/2023 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20230427130506

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: 170	DATE:	04/03/2024
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Ginger Enriquez		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident sustained a fracture while in care
Staff failed to seek medical attention for resident in a timely manner

INVESTIGATION FINDINGS:

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On 04/03/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced visit to the facility listed above to deliver complaint findings. LPA met with Assistant Administrator, Ginger Enriquez, and explained the purpose of today’s visit.

On 04/28/23, Licensing Program Analyst (LPA), Wendy Gibbs conducted an unannounced complaint visit to the facility listed above. Upon arrival LPA Gibbs conducted a risk assessment before entering to ensure the facility is free of Covid-19. LPA Gibbs met with MedTech, Julie Ann Villanueva, and explained the purpose of today’s visit. We were later joined by Assistant Administrator, Ginger Enriquez.
The visit consisted of LPA received documents pertinent to the investigation. The following documents were received and reviewed staff roster, client roster, physicians report, face sheet, preplacement appraisal, needs and service plan, nurse notes, and medication administration record (MAR) for R1.

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

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 4

Control Number 11-AS-20230427130506

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
	VISIT DATE: 04/03/2024

NARRATIVE

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The investigation consisted of the following: LPA conducted the initial 24-hour visit and requested copies of pertinent documents. The complaint was accepted by CCL IB Investigation Unit and assigned to IB investigator Heidy Bendana. IB investigator Bendana conducted and completed the investigation which included interviews with Assistant Administrator, facility staff, residents, resident R1’s conservator, Social Worker Director at Edgewater Skilled Nursing, and Harbor UCLA Medical Center Clinical Social worker, reviewed Harbor-UCLA Medical Center Medical Records, and resident R1 facility records.

Allegation: Resident sustained a fracture while in care

It is alleged staff failed to supervise Resident R1 resulting in hospitalization for a fracture.
During file record review it was notated R1 is independent. R1’s Physicians Report indicated R1 was “Able to Leave Facility Unassisted,” Able to Bathe, Dress, Groom, and Feed Self,” and did not require assistance with using the restroom or transferring. Appraisal/Needs and Services Plan listed R1 as ambulatory with the capacity to self-care and able to do all ADL’s, there was no indication that R1 was a fall risk. R1 was not feeble or slow and did not require assistance. During interviews with Staff S1-S3, they were asked, by the IB investigator, if R1 required assistance, three (3) out of three (3) stated R1 is independent and did not require assistance. Additionally, Staff (S1-S3) were asked if they were aware of R1 falling, three (3) out of three (3) stated they did not know R1 experienced a fall until R1 reported it to the hospital. During an interview with Staff S2, told the IB investigator, on 04/26/23 R1 was in their rocking chair, their face droopy, their speech was stuttered and not normal, therefore S2 called 911. S2 was informed

Continued on LIC9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20230427130506

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
	VISIT DATE: 04/03/2024

NARRATIVE

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by the hospital that R1 had a fall on 04/22/23. During an interview with R1’s Responsible Party (W1), conducted by IB investigator, stated they did not believe R1 was a fall risk.

During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the above allegation did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Staff failed to seek medical attention for resident in a timely manner.

It is alleged that staff did not seek medical attention for Resident R1 in a timely manner.
It was reported that Resident R1 had a fall on April 22, 2023, that resulted in a left femoral neck hip fracture. During interviews, conducted by IB investigator, with Staff S1-S4, they were asked if they had any knowledge of the fall R1 had, four (4) out of four (4) stated they had no knowledge of R1 having a fall, they did not receive that information until R1 reported to the hospital on April 26, 2023, they had a fall on April 22, 2023. On April 26, 2023, Resident R1 was transferred to the hospital due to R1’s face being droopy, stuttering, and speech not being normal. During an interview with MedTech S2 stated on April 25, 2023, R1 told them they were having leg pain and had given them pain medication, and that in the past, R1
frequently complained of leg pain. Additionally, during an interview S2, stated they did not remember if R1 reported a fall. During interviews, conducted by the IB investigator, with Residents R2 and R3, two (2) out of two (2) stated they receive assistance and medical assistance in a timely manner.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20230427130506

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
	VISIT DATE: 04/03/2024

NARRATIVE

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No deficiencies were observed or cited.

An exit interview was conducted with Assistant Administrator, Ginger Enriquez,, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

LIC9099 (FAS) - (06/04)

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