198204950-2-25-2024-11-AS-JHAD-D2WUB6-20240229142549

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 02/23/2024
Date Signed: 02/25/2024 10:33:26 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/31/2023 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20231031134927

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: 171	DATE:	02/23/2024
		UNANNOUNCED	TIME BEGAN:	08:06 AM
MET WITH:	Ginger Enriquez		TIME COMPLETED:	04:07 PM

ALLEGATION(S):

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Staff threatened resident while in care.
Staff did not safeguard resident's personal belongings.
Staff did not provide a safe and comfortable environment for residents.

INVESTIGATION FINDINGS:

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On 02/23/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent complaint visit at this facility. The LPA was greeted by Ginger Enriquez, the administrator. The purpose of this inspection visit is to gather information regarding the allegations mentioned above and to deliver findings was explained to Enriquez.

The investigation consisted of the following: A review of the facility's roster for residents and staff. Interviews with residents #1-#10 (R1-R11), staff #1-#3 (S1-S3), and administrator #1 (A1). A review of (R1's) Service Records, Physician's Report, Resident Appraisal, Face Sheet, Appraisal/Need and Service Plan, Admissions Physician's Orders, Resident Personal Property and Valuables, Admission Agreement, Medication Administration Record, and other pertinent records associated with the allegations. A tour of the facility on 02/23/24 and 11/08/23.

(Evaluation Report continues LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

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 3

Control Number 11-AS-20231031134927

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
	VISIT DATE: 02/23/2024

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: Staff threatened resident while in care.
Allegation #3: Staff did not provide a safe and comfortable environment for residents.

The details of this allegation claimed that resident #1 (R1) was threatened by administrator #1 (A1). According to the reporting party (R1) was threatened by (A1) that (R1’s) personal property would be thrown away and that (A1) had threatened (R1) in the past. As a result of feeling threatened (R1) did not feel the facility provided a safe and comfortable environment for (R1) and other residents.

On 02/23/24 at 12: 47 pm – 12: 58 pm the Department interviewed (R1) by telephone. (R1) claimed that (R1) had enjoyed living at the facility for (22). However, (R1) was threatened by (A1) who (R1) is unable able to identify by name. (R1) is unable to provide further information such as details on dates, times, and incidents that have occurred with (A1) where (R1) may have felt threatened. (R1) responded, "Yes", "I liked living there and I felt safe" when asked whether this facility provided a comfortable place to live.

On 02/23/24 between 09:15 am – 10:30 am, the Department interviewed administrator #1 (A1), and staff #1-#3 (S1-S3) reported (4) out (4) verified that this allegation is untrue. (A1) claimed to have never threatened (R1) since (R1’s) residency at the facility. (S1) has simply followed up with (R1) regarding (R1’s) residency since (R1) had not returned to the facility since (R1’s) hospitalization on 09/12/23. (R1) had not given notice whether (R1) would remain as a resident. The facility continued to retain all of (R1's) personal property safeguarded and protected until (R1) had given notice to terminate residence. (S1-S4) stated that we have installed surveillance cameras, safety devices, smoke detectors, house rules, mandated elder abuse training, and emergency preparedness training to mitigate the risks of an unsafe environment.

On 02/23/24 between 9:30 am – 11:50 am, the Department interviewed residents #2-#11 (R2-R11) (10) out (10) who are complimentary of (A1) and staff. (R2-R11) claimed they had not been threatened by (A1) or any of the staff. (R2-R11) all guaranteed they felt the facility has provided a safe and comfortable environment for residents. As a result of the information gathered, there is no evidence to support the allegations mentioned above.

(Evaluation Report continues LIC 9099-C)

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20231031134927

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
	VISIT DATE: 02/23/2024

NARRATIVE

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Allegation #2: Staff did not safeguard resident’s personal belongings.

The details of this allegation reported that the facility failed to safeguard resident #1 (R1’s) personal belongings. On 02/23/24 at 12: 47 pm – 12: 58 pm the Department interviewed (R1) by telephone. (R1) claimed the facility failed to safeguard her personal property on the day she was transported to Harbor Regional Medical Center on 09/12/23. (R1) claimed to have observed individuals in and out of (R1’s) room and that money that was stored in a portable refrigerator with a lock was stolen. (R1) could not describe the individuals nor unable to determine the roles of the individuals in the facility.

On 02/23/24 between 09:15 am – 10:30 am, the Department interviewed administrator #1 (A1), and staff #1-#3 (S1-S3) reported (4) out (4) verified that this allegation is false. (A1 and S1) claimed (R1) has been a resident for 19 years and has never had any issues with property not safeguarded. (A1 and S1) reported when (R1) was admitted to the hospital on 09/12/23, (R1’s) personal belongings remained in the room locked. (A1) unaware of how long (R1) was going to be away from the facility placed all (R1’s) personal items in an unoccupied locked room room #203. The Department verified all the items listed on (R1’s) Resident Personal Property and Valuables LIC 624 which listed (14) personal property items and (14) were accountable. From 10:26 am – 10:29 am, the Department took photographs of the items as evidence. The Department observed a portable refrigerator sealed with a padlock required a key to open.

On 02/23/24 between 9:30 am – 11:50 am the Department interviewed residents #2-#11 (R2-R11) (10) out of (10) all confirmed their personal belongings were safeguarded and have not gone missing. On 02/23/24 at 10:10 am, (R1) effectively voluntarily terminated her residency with the facility when (R1) authorized in writing for (R1’s) guardian witness #1 (W1) to retrieve (R1’s) personal property. As indicated in (R1’s) discharge summary, “(W1) went up to the storage room and picked out what (W1) wanted to take with (W1)”. (W1) declined to be interviewed by the Department. As a result of the information gathered, there is no evidence to support the allegation mentioned above.

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

An exit interview was conducted with Ginger Enriquez, and copies of the reports were provided.

SUPERVISOR'S NAME: Janae Hammond	TELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand Dabuet	TELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2024

LIC9099 (FAS) - (06/04)

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