<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204950
Report Date: 04/20/2023
Date Signed: 04/25/2023 09:14:37 PM

Document Has Been Signed on 04/25/2023 09:14 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:CARSON SENIOR ASSISTED LIVINGFACILITY NUMBER:
198204950
ADMINISTRATOR:SHOLOM GOLDMANFACILITY TYPE:
740
ADDRESS:345 EAST CARSON STREETTELEPHONE:
(310) 830-4010
CITY:CARSONSTATE: CAZIP CODE:
90745
CAPACITY: 230CENSUS: DATE:
04/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:34 PM
MET WITH:Ginger Enriquez TIME COMPLETED:
02:01 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 04/20/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent case management visit at this facility. LPA met with assistant administrator Ginger Enriquez and explained the purpose of the visit. LPA is to issue the final results of the death investigation of resident # 1 (R1).

The regional office received a copy of the death report from the facility and reported the death of (R1) on 09/02/22. The death report stated on 08/26/22 (R1) was declared dead at a park in Pomona, California reported by Investigator K. Anderson of the Pomona Police Department. The facility staff had last seen (R1) on 08/26/22 after breakfast at the facility and left the premises on his own for his daily outing. The Department interviewed the family member of the resident and administrator Ginger Enriquez.

A police report was obtained and a death certificate revealed that (R1’s) cause of death on 08/26/22 was due to a some type of drug overdose. Law enforcement performed life saving measures but were not successful in reviving (R1). According to law enforcement, signs of foul play were not evident. Death certificate indicated, "DEFERRED", after an autopsy, caused of death has not been determined and the medical examiner is requesting more investigation into the death, including additional studies.

Based on information gathered, the Department found no evidence of negligence or foul play by the facility and will now close this investigation.

An exit interview is conducted with Ginger Enriquez and a copy of the report is provided.

This report serves as an amendment to clarify lines # 12, #13 & #18. It does not supersedes the investigation conclusion reflected on report created 04/20/23.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1