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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 07/07/2025
Date Signed: 07/07/2025 03:47:13 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
07/03/2025 and conducted by Evaluator Antonine Richard
COMPLAINT CONTROL NUMBER: 11-AS-20250703114547
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: 45DATE:
07/07/2025
UNANNOUNCEDTIME BEGAN:
07:58 AM
MET WITH:Enriquez GingerTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff Physically assaulted resident causing injury.
INVESTIGATION FINDINGS:
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On 07/07/2025, Licensing Program Analyst (LPA), Antonine Richard conducted an initial visit to gather information regarding the above allegation. LPA met with Enriquez Ginger, the assisted living Administrator, and the purpose of the visit was explained. LPA toured the facility.

The investigation included the following steps: On July 7, 2025, LPA Richard reviewed and collected various documents, including the Facility Resident Roster (dated July 7, 2025) and the Personnel Report LIC 500 (also dated July 7, 2025). Additionally, LPA obtained and reviewed Resident #1's (R1) Face Sheet for ID and Emergency Information LIC 601 (dated April 21, 2025), the Physician Report LIC 602A (dated December 20, 2024), and the Preplacement Appraisal Information LIC 603 (dated April 21, 2025). Other documents reviewed included the Admissions Agreement LIC604A (dated April 21, 2025) and the Appraisal/Needs and Services Plan (dated April 21, 2025), along with any other relevant records related to this allegation. Interviews were conducted with residents #2-#7 (R2-R7), staff members #1-5 (S1-S5), and the Client Wellness Program Manager (CWPM) from DHS.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2025
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-20250703114547
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: 07/07/2025
NARRATIVE
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Allegation: Staff physically assaulted resident causing injury.

The complaint alleges that the staff " verbally and physically abused the resident, resulting in bruises, scratches, on left knee and left wrist" On July 7, 2025, between 9:20 AM and 10:45 AM, the LPA interviewed five staff members (S1-S5), all of whom denied the allegation and stated that no staff member has ever hit or verbally abused a resident in their care.

Later, on the same day, from 11:00 AM to 01:00 PM, LPA Richard interviewed eight residents (R2-R9). Seven out of eight residents denied the allegation, affirming that the staff never verbally abused or physically hit them or witnessed staff hitting any residents. However, they reported having observed residents fighting among themselves, with staff intervening to separate them.

At 12:10 PM on July 7, 2025, LPA Richard called and spoke with the Client Wellness Program Manager (CWPM) from DHS. The CWPM denied the allegation and mentioned that they are collaborating with the Medical Case Worker (MCW) from DHS to transfer Resident #1 (R1) to a different facility, as R1 requires a higher level of care.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20250703114547
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: 07/07/2025
NARRATIVE
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Additionally, LPA reviewed incident reports and photos of R1, dated July 1, 2025, which showed no bruises or scratches on R1's left wrist or arms. LPA was unable to interview R1 because the resident was in the hospital. Based on the information collected, there is no evidence to support the allegations made.

Based on information gathered, an inspection of the facility, observation, and interviews conducted, an analysis of records reviewed, the LPA 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.

No deficiencies were cited.

An exit interview was conducted. A copy of the report was provided to the Assisted Living Administrator Ginger Enriquez.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3