198204950-7-2-2021-11-AS-EMAZ-C5JU43-20210803151427

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 07/01/2021
Date Signed: 07/02/2021 01:55:21 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:	07/01/2021
		UNANNOUNCED	TIME BEGAN:	09:14 AM
MET WITH:	GINGER ENRIQUEZ		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Resident's mattress needs replacing.
Staff does not ensure that resident receives medications.
Resident was left on the ground for an extended period after falling.

INVESTIGATION FINDINGS:

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On 07/01/21, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced subsequent complaint visit at this facility. LPA met with Ginger Enriquez, Administrator, and explained the purpose of today's visit is to conduct additional interviews with staff to deliver findings.

The investigation consisted of the following: LPA interviewed Ginger Enriquez. Interviews were conducted with five (4) staff, two (1) witnesses, and (10) residents. LPA inspected the facility. LPA requested copies of service records concerning (R1) along with the current staff/resident roster and other documents in association with the allegation.

Evaluation Report continues on LIC9099-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: 07/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021

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-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: 07/01/2021

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Resident’s mattress needs replacing.
The complainant reports resident #1 (R1)’s mattress needs replacing. An interview with (R-1) states she does not know how old her mattress, and that it sags and makes it unbearable for her to get off it. (R-1) claims she did not purchase the mattress. The mattress was provided by the facility when she moved in. An interview with resident #2 (R-2) claims she did not know her roommate had problems with her mattress as she never voiced her discomfort. In an interview with Ginger Enriquez, the administrator states she examined the mattress on 06/28/20 and found the mattress to be firm and in good condition. Nonetheless, Enriquez went ahead and replaced (R-1)’s mattress with a brand new one effective 06/29/21. An interview with Mata Filooialii of Adult Protective Services who conducted a visit on 06/28/21 and 06/29/21, confirms she was present during the exchanges of mattresses and can verify that the facility had replaced (R1)’s mattress with a brand new one. An interview with residents #2-10 (R2-R10) reports they have no issues with any of their furnishings supplied by the facility and states it is adequate and in good condition.

During this investigation on 06/30/21, LPA examined (R-1)’s mattress and can validate that a new mattress is in place. Based on information gathered, observation, interviews, there is no evidence to corroborate the allegation mentioned above.

Allegation: Staff does not ensure that resident receives medications.
The complainant reports resident #1 (R-1) does not receive her pain medications timely. An interview with (R-1) states she is often in pain and will resort to alcohol to remedy the pain if not available. (R-1) does admit that she receives all her prescribed medications and that the facility has not missed a single dosage. An interview with staff #2 (S-2) claims the pain medication is used to help relieve moderate to moderately severe pain and it is taken only as required. It is not to be taken daily according to (R1)’s physician. (S-2) claims medications are distributed daily at 8 am in the dining room area. (S-2) states when a resident is not present during the normal distribution process, med-techs will make individual visits to each resident not present during the normal process to ensure all residents received their daily meds. An interview with (R2-R10) all claimed they have no issues in receiving their medications timely manner.

Evaluation Report Continues on LIC-9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021

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
	VISIT DATE: 07/01/2021

NARRATIVE

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During this investigation on 06/30/21, LPA examined (R-1)’s Medication Administration Records (MAR) and found the records are maintained in order, accurate, and complete. Based on information gathered, observation, interviews, service records, there is no evidence to support the allegation mentioned above.

Allegation: Resident was left on the ground for an extended period after falling.
It is alleged the staff neglected (R-1) for an extended period after a fall. The complainant claims (R-1) was left for several hours after a fall on 06/23/21 and that no immediate assistance was provided. An interview with (R-1) claims she had fallen due to the carpet had frayed in her room around 4:30 am while going to the toilet. (R-1) states she did not use her walker and that the night light in the bathroom was working properly. (R-1) reports she fell in her room and that she crawled inside the bathroom where she cried for help. Moreover, (R-1) claims she was not calling for staff assistance, but for her roommate (R-2) to help who was asleep during the incident. (R-2) claims that she did not observe (R-1)’s actual fall and only heard (R-1) cry for help around 6:30 am. (R-2) states all she did was dispatched for staff who arrived immediately. An interview with staff #3-#4 (S3-S4) both assisted (R-1) disputes her claim. (S-3) states she was doing her normal routine rounds between 4:00 am – 4:30 am and at the time she was in room 211. (S-2) claims she would have heard (R-1) cry for help. (S-4) claims when she asked (R-1) what had happened, (R-1) reported she fell due to some personal items sitting on the floor and she lost her balance, and that she fell inside the bathroom. (S1-S4) all indicated that (R-1) received immediate assistance and that 911 was dispatched and that (R-1) was taken for medical evaluation. (S1-S4) claimed the proper emergency procedures were applied and that Community Care Licensing, Adult Protective Services, and Ombudsman were notified. An interview family member (W-3) indicated that (R-1) tends to embellish her stories. (W-3) reports the facility has done a satisfactory job of care and supervision for (R-1) and claims the reason (R-1) has maintained a long-term residency at this facility. Interviews conducted with (R2-R10) all verified that staff are attentive to their care and supervision and have not encountered any type of neglect.

During the inspection, LPA observed (R-1)’s room to be an intimate size of 12’ x 14’ and that any sound effect will be stronger in a small room and that (R-1)'s call for help would have been heard by her roommate (R-2) at 4:30 am when any noise would have been minimal.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 4

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: 07/01/2021

NARRATIVE

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Furthermore, (R1)'s statements are inconsistent with her roommate (R-2) and (S3-S4) accounts of what had happened during the incident. Based on information gathered, observation, interviews, records, and other pertinent resources reviewed, there is no evidence to corroborate the allegation mentioned above.

The Department’s investigation consisted of an inspection of the facility, observation, analysis of (R1’s) service records, incident report, (MAR), and interviews conducted and found no evidence to support the allegations: "Resident's mattress needs replacing", "Staff does not ensure that resident receives medications", and "Resident was left on the ground for an extended period after falling".

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations, did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted with Ginger Enriquez and a copy of the report was provided by email.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 629-7047
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021

LIC9099 (FAS) - (06/04)

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