198204950-12-3-2023-11-AS-JHAD-CY7QYL-20231204113518

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 12/02/2023
Date Signed: 12/03/2023 11:09:41 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
03/17/2021 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20210317104047

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: 162	DATE:	12/02/2023
		UNANNOUNCED	TIME BEGAN:	01:50 PM
MET WITH:	Beverly Malacas		TIME COMPLETED:	03:44 PM

ALLEGATION(S):

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Facility staff did not observe change in resident's health conditions.
Facility neglected well care check ups for resident in care.

INVESTIGATION FINDINGS:

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On 12/02/23, Licensing Program Analyst (LPA) Ernand Dabuet subsequent an unannounced complaint visit at this facility. LPA met with Med Tech Beverly Malacas, and explained the purpose of today's visit is to deliver findings for the the allegations mentioned above.

The investigation consisted of the following: Interviews with staff #1-#5, residents #1-#10, witnessess #1-#5, review of staff roster, resident roster, (R1's) service records, medical records, Incontinent 2-hour check logs, and other pertinent documents associated to this complaint. A tour of the facility on 03/18/21, 07/30/21, 09/27/23, and 12/01/23.

Evaluation Report continues on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2023

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-20210317104047

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
	VISIT DATE: 12/02/2023

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #3: Facility staff did not observe change in resident's health conditions.
Allegation #4: Facility neglected well care checkups for resident in care.

The details of the complaint alleged the facility did not observe the change in resident #1 (R1) condition and neglected the wellness care checkup for (R1). The complainant claimed the (R1) was exposed to an infection and had general weakness of muscles.

A review of (R1's) service records and medical records revealed, (R1) medical checkups were performed with the in-house physicians. Records indicated physician visits listed: 09/20/18,11/19/18, 12/12/18, 08/28/19, 02/19/20, 12/17/19, 01/17/20, 02/19/20, 08/13/20, 08/17/20, 09/03/20, and 09/13/20. Psychiatric Assessments were conducted monthly from 12/12/18 through 12/31/20. Physician's Report LIC 602A was performed on annually on 11/19/18, 12/17/19, 01/20/20, and 02/19/20. (R1's) Appraisal/Needs and Services Plan LIC 625 were performed on 06/19/1810/16/19, 01/17/20. (R1) records indicated, that (R1) was being observed by staff every (2) hours daily on each shift according to Incontinent 2-hour check logs.

On 09/27/23, interviews were conducted between 10:00 am and 3:11 pm with (9) out (9) residents #2 - #10 (R2-R10) were complimentary of staff. (R2-R10) recognized that staff have challenging duties and remain to be attentive and responsive.

On 09/27/23, interviews were conducted between 10:37 am and 12:43 pm with (5) out (5) family representatives witness #1-#5 (W1-W5) reported they did not have any concerns for their health and safety and medical assistance was available for residents at all times. (W1-W5) described the care and supervision as sufficient.

On 12/01/23, interviews conducted between 11:00 am and 1:00 pm (5) out of (5) staff # 1- #5 (S1-S5) claimed care and supervision for (R1) continuous around-the-clock daily. (S1-S2) claimed, (R1) did present a decline in his health condition. (R1) was being medically assessed in-house by medical professionals, and (R1's) wellness checkups were performed in the facility.

Evaluation Report continues LIC 9099-C

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2023

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20210317104047

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
	VISIT DATE: 12/02/2023

NARRATIVE

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Several attempts to interview (R1) on 09/27/23 and 11/27/23 were unsuccessful. (R1’s) health condition prevented (R1) from carrying on full conversations. (R1's) Case Workers were not available for an interview. Based on all the information obtained during the investigation, there is no evidence to support the allegations mentioned above.

Based on the information gathered, an inspection of the facility, observation, and interviews conducted, an analysis of records reviewed, the Department found no evidence to support the allegations mentioned above.

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 Beverly Malacas, and copies of the reports were provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2023

LIC9099 (FAS) - (06/04)

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