198204950-4-9-2021-11-AS-MVAO-C3LNEC-20210602102344

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 04/08/2021
Date Signed: 04/09/2021 01:06:18 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
03/08/2021 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210308092055

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: 164	DATE:	04/08/2021
		UNANNOUNCED	TIME BEGAN:	02:41 PM
MET WITH:	Gabriela Eusebio & Ginger Enriquez		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Facility did not have grab bars.
Facility did not have hot water.

INVESTIGATION FINDINGS:

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On 04/08/21, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint tele-visit at this facility, Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) Pandemic, and to implement mitigation measures, today’s complaint investigation was conducted telephonically with Gabby Eusebio/Supervisor and Ginger Enriquez/Administrator. LPA/Dabuet explained the purpose of today's tele-investigation.

The investigation consisted of the following: Interviews with staff #1-#2 (S1-S2) residnet #1 (R1) and witnesses #1-#3 (W1-W3), a review of consumers' service records, and other pertinent documents associated with this complaint. A virtual tour of the entire facility was conducted on 03/17/21 and 04/08/21.

Evaluation Report Continues on LIC 9099-C

Unsubstantiated

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: 04/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2021

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-20210308092055

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: 04/08/2021

NARRATIVE

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Allegations: Facility did not have grab bars.
Facility did not have hot water.

It was alleged that this facility failed to have grab bars and hot water for resident #1 in (R1's) bathroom.
LPA conducted a virtual tour of the facility on 04/08/21 and an inspection of resident #1 (R1's) room in Arbor Hall, an interview with staff #1-#2 (S1-S2), resident #1 (R1), and witness #1-#4 (W1-W4) and found there is no evidence to corroborate the allegation mentioned above. An interview with (R1) revealed that he is completely comfortable and content with his care at this facility and that his needs and services are met. (R1) states he has no problems accessing hot water or grab bars in his room. An interview with (W2-W4) revealed that there is no immediate health or safety concern and that (R1’s) services are being fulfilled by the staff at this facility. According to (W4) she is the power of attorney for (R1) and had done extensive research along with a social worker in selecting this facility to admit (R1). (R1) has now lived here at this facility in the same room for (6) years and (W4) claims she has had no complaints report in regards to staff or the facility. In an interview with (W4), she expressed there is discontent with a family member from out of state and would prefer (R1) to reside and be cared for in a private home. An interview with a family member (W1) confirmed she would prefer (R1) to in private home and that these allegations stem from her visit in 2019 at this facility and not from a recent visit. An interview with (S1) claims that routine maintenance checks of each room are done weekly. An interview with the social worker (W3) confirms that a visit to (R1) every month is conducted and has determined that no issues with (R1’s) care or living conditions. During an inspection visit on 04/08/21, LPA observed the (R1’s) room to be clean, safe, sanitary, and maintained in order. In (R1's) bathroom was equipped with grab bars, hot and cold water supply, and plumbing fixtures in working condition. Based on observation, record reviews, and interviews there's no evidence to support the allegations mentioned above.

Based on information gathered, the Department did not find sufficient evidence to support the allegations: "The "Facility did not have grab bars" and "Facility did not have hot water".

Although the allegations may have happened or are valid, there is not enough preponderance of evidence to prove the alleged allegations are valid did or did not occur. Therefore, the allegations are "unsubstantiated.”

A telephonic exit interview was conducted with Ginger Enriquez, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2021

LIC9099 (FAS) - (06/04)

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