198204950-6-30-2021-11-AS-EMAZ-C5JU44-20210803151429

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 06/30/2021
Date Signed: 06/30/2021 09:11:44 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/25/2021 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210625134143

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: 176	DATE:	06/30/2021
		UNANNOUNCED	TIME BEGAN:	08:57 AM
MET WITH:	GINGER ENRIQUEZ		TIME COMPLETED:	04:25 PM

ALLEGATION(S):

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Facility is in disrepair/frayed carpet.

INVESTIGATION FINDINGS:

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On 06/30/21, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced initial 10-day complaint visit at this facility. LPA met with Ginger Enriquez, Administrator, and explained the purpose of today's visit is to gather information regarding the allegation above.

The investigation consisted of the following: LPA interviewed Ginger Enriquez. LPA inquired questions relevant to the nature of the complaint and incident report. An interview with resident #1-#2 (R1-R2). A telephone interview with Mata Filoialii of Adult Protectives Services and a plant inspection of the entire facility was conducted.

Evaluation Report Continues on LIC 9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210625134143

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
	VISIT DATE: 06/30/2021

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: "Facility is in disrepair/frayed carpet"

The complainant reported the carpeting in resident #1 (R-1)'s room is unraveling and may have caused (R1)'s fall. LPA interviewed resident #1-#2 (R1-R2) both residents share room 220 and was not able to describe where the precise location of where carpet fibers have frayed or separated. (R-1) states she has always been concerned about the carpeting but has never mentioned her concerns with the management staff. (R-2) reports she has no concerns about carpeting in the room and is completely satisfied. An interviewed Mata Fiilooialii of Adult Protective Services who had conducted an in-person inspection on 06/28/20 and 06/29/20 further verified that (R1) was not able to provide the exact location of her fall and what part of the carpeting was frayed. LPA inspected (R1)'s room and did not observe visible carpet fibers frayed and separated in room 220. At 10:55 am, LPA observed on the second floor underneath the exit sign adjacent to room 280; carpet fibers that have frayed and separated. According to Fiiloalii, she had observed the same safety hazard during her visit on 06/29/21 and informed the administrator. During the interview with the administrator she confirmed she was made aware of safety hazard and that a replacement of carpeting is scheduled for 07/01/21 for the high traffic sections on the second floor including (R1)'s room 220.

Based on LPA’s observation and interviews conducted, the preponderance of evidence standard has been met, therefore the allegation of "Facility is in disrepair/frayed carpet" is found to be: Substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC 9099-D.

An exit interview was conducted with Ginger Enriquez. The Rights were discussed and a copy of Appeals Procedures for Licensees was provided, as well as a copy of this report to the Administrator.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2021

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210625134143

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTERY PARK, CA 91754

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/30/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/08/2021 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation. The facility shall be clean, safe, sanitary, and in good repair at all times. Maintenance shall include the provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The administrator will ensure that the items listed under this deficiency have been corrected to ensure compliance with California Code of Regulations Title 22, Section 87303 and provide proof of correction to CCL by the POC due date: 07/08/21.
	8 9 10 11 12 13 14	LPA observed on 06/30/21 at 10:55 am on the second floor underneath the exit sign adjacent to room 280; the carpet fibers have frayed and separated which causes a safety issue. This is a violation that poses a potential Health and Safety or Personal Rights risk in residents in care.	8 9 10 11 12 13 14	This violation was corrected during the visit on 06/30/21. LPA observed the carpet floor was masked with heavy-duty commercial tape and that a new replacement carpet will take place on 07/01/21.
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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: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2021

LIC9099 (FAS) - (06/04)

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