198204950-10-30-2025-11-AS-SCIS-DN74VY-20251106182708

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 09/25/2025
Date Signed: 10/30/2025 12:25:21 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, 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
08/27/2025 and conducted by Evaluator Pamela Bunker

COMPLAINT CONTROL NUMBER: 11-AS-20250827083449

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: 166	DATE:	09/25/2025
		UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Ginger Enriquez and Julie Villanueva		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Staff wrongfully evicted resident.

INVESTIGATION FINDINGS:

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On 09/25/2025, Licensing Program Analyst (LPA) Pamela Bunker conducted an subsequent visit to gather information regarding the above allegation. LPA met with Ginger Enriquez, Assistant Administrator, and explained the purpose of the visit. LPA was granted entry to the facility.

The investigation consisted of the following: On September 03, 2025, the following documents were reviewed and obtained as part of the investigation: Personnel Report (dated 09/03/2025), Resident Roster (dated 09/03/2025), 30-day Eviction Notice (dated 08/08/2025), Unusual Incident Report (dated 08/20/2025), Admission Agreement (dated 10/24/2023) Identification and Emergency Information (dated 10/24/2023 ), Physician’s Report (dated 03/27/2025), Medical Assessment (dated 03/27/2025), Medication Administration Records (MARs) (dated 08/01/2025-09/01/2025), Appraisal & Needs and Services Plan (dated 11/13/2024), Functional Capability Assessment (dated 11/13/2024), Preplacement Appraisal Information (dated 11/13/2024), Personal Rights (dated 10/24/2023), Consent Forms (dated 10/24/2023), House Rules (dated 10/24/2023), Los Angeles County Sheriff Report (date 08/20/2025), See continued LIC9099-C page 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025

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-20250827083449

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
	VISIT DATE: 09/25/2025

NARRATIVE

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Continued LIC9099-C page 2

and Unusual Incident Reports (dated 07/18/2025 - 09/02/2025).

On 09/25/2025, at 11:40 A.M. - 4:00 p.m., LPA Bunker interviewed Staff members #1-#4 (S1-S4) and residents #1-#8 (S1-S8).

The investigation revealed the following:
Allegation: Staff wrongfully evicted a resident.
It has been alleged that staff wrongfully evicted a resident.

On September 3, 2025, and September 25, 2025, LPA Bunker interviewed staff members #1 through #4 (S1–S4). LPA asked whether any resident was being wrongfully evicted. All four staff members interviewed (4 out of 4) answered no. They stated that R1 is still a resident and did not receive a three-day eviction notice.

LPA Bunker reviewed R1’s Admission Agreement, which was dated and signed on October 24, 2023. On the same date, R1 also signed the House Rules. LPA Bunker reviewed Unusual Incident Reports dated between July 18, 2025, and September 2, 2025, and observed 14 incidents involving R1’s ongoing aggressive behavior toward staff and residents, including combative actions and harassment. S1-S4 stated that the 30-day eviction notice and the Special Incident Reports were submitted to CCLD in a timely manner.

LPA also reviewed the Los Angeles Sheriff’s report dated August 20, 2025, and a 30-day eviction notice dated August 20, 2025. There is no record on file indicating that the facility provided R1 with a three-day eviction notice or that staff wrongfully evicted resident #1. Staff members #1 through #4 (S1–S4) denied the allegation.

LPA interviewed residents #1 through #8 (R1–R8). Residents interviewed (7 out of 8) answered no when asked if a resident was being wrongfully evicted. R1 stated that staff provided a 30-day eviction notice dated August 20, 2025, and confirmed that they never received a three eviction notice and no hard copy of a three-day notice was provided. Seven out of eight residents denied the allegation.
See Continued LIC9099-C page 3

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20250827083449

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: CARSON SENIOR ASSISTED LIVING	FACILITY NUMBER: 198204950
	VISIT DATE: 09/25/2025

NARRATIVE

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Continued LIC9099-C page 3

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegation. 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 deemed unsubstantiated.

A copy of the Complaint Investigation Report LIC9099 and LIC9099-C was provided to the facility Med Tech/Resident Coordinator Julie Villanueva.

There were no deficiencies cited.

An exit interview was conducted.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 09/25/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2025

LIC9099 (FAS) - (06/04)

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