198204950-11-20-2023-11-AS-JHAD-CY7QZW-20231204113725

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 11/20/2023
Date Signed: 11/20/2023 09:36:32 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
11/15/2023 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20231115152702

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:	11/20/2023
		UNANNOUNCED	TIME BEGAN:	12:55 PM
MET WITH:	Ginger Enriquez		TIME COMPLETED:	04:59 PM

ALLEGATION(S):

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Facility has pests.

INVESTIGATION FINDINGS:

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On 11/20/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a complaint visit at this facility. LPA was greeted by administrator Ginger Enriquez. This inspection visit is to gather information for the allegation mentioned above and deliver findings.

The investigation consisted of the following: A review of the facility's roster for residents and staff. Interviews with residents #1-#10 (R1-R10), witnesses #1-(W1). A review of pest control contract and monthly services receipts. A physical tour of the facilty was conducted.

(Evaluation Report continues 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: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

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-20231115152702

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: 11/20/2023

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation: Facility has pests.

The details of the complaint reported the facility has pests. The complainant reported the facility has "multiple cockroaches on the wall". The complainant did not provide further information on who was involved, where in the facility or when it took place.

A full inspection of the entire facility was conducted by the Department, including the dining room, kitchen, activity rooms, library, medication, offices, public restrooms, and elevators. In Arbor Hall, the following rooms were inspected: #5, #7, #20, #21, #25, #26 and #27. In the Assisted Living, the following rooms were inspected: #2, #13, #20, #23, #30, #101, #102, #205, #209, #214, #267 and #284. During the inspection, no signs of pest infestation were observed on walls, floors, furnishings, or equipment.

On 11/20/23 between 2:00 pm - 3:47 pm interviews with (7) out of (10) resident #1-#7 (R1-R7) indicated having no issues with pest in the common areas or individual rooms. (R8-R10) reported cockroaches were seen in their rooms; however, the facility sprays to eliminate the problem. Staff #1 (S1) stated the pest control company come to service the facility twice a week for the kitchen. Gam Exterminating Inc. comes to service the facility weekly or as needed. (S1) reported the facility has an annual service contract agreement with Gam Exterminating Inc. The facility provided maintenance service receipts along with the service contract as proof services are maintained. Based on the information gathered, the allegation mentioned above cannot be supported.

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

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

An exit interview was conducted with Ginger Enriquez, 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: 11/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2023

LIC9099 (FAS) - (06/04)

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