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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204950
Report Date: 12/11/2025
Date Signed: 12/11/2025 04:19:07 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
12/05/2025 and conducted by Evaluator Alfonso Iniguez
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20251205101712
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:
12/11/2025
UNANNOUNCEDTIME BEGAN:
09:38 AM
MET WITH:Ginger Enriquez/Facility AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff did not prevent a resident from sexually abusing another resident
INVESTIGATION FINDINGS:
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On 12/11/2025 at approximately 9:30 AM, LPA Alfonso Iniguez conducted an unannounced subsequent complaint visit. LPA Iniguez met with Ginger Enriquez/ Facility Administrator. LPA Iniguez explained the purpose of this visit.

Investigation Consisted of: LPA conducted the following interviews: Facility Administrator Interview (A#1), Resident Interviews (R#1-R#10) and Witness Interview (W#1). LPA gathered the following documents: Resident Roster dated: 11/21/25, Staff Roster dated:12/11/25, copy of (R#1) Physician’s Report for Residential Care Facilities for the Elderly (RCFE) or LIC 602 dated:6/25/25, copy of (R#1)’s medication list, copy of (R#1)’s Identification and Emergency Information or LIC 601, copy of (R#1)’s Resident Appraisal or LIC 603A date:9/24/25, and copy or (R#1)’s Appraisal/Needs and Services Plan or LIC 625 dated:9/24/25.

Evaluation Report continues LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
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 4
Control Number 11-AS-20251205101712
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: 12/11/2025
NARRATIVE
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 Investigation Revealed the Following:

Allegation: Staff did not prevent a resident from sexually abusing another resident

The details of the complaint alleged that (R#1) was sexually assaulted by (R#2).

On December 11, 2025, at approximately 12:00 p.m., during a review of records, Licensing Program Analyst (LPA) Iniguez observed Resident #1’s (R#1) Physician’s Report for Residential Care Facilities for the Elderly (LIC 602A), dated June 25, 2025. The report indicates that (R#1) has been diagnosed with a mental health condition that may influence their thought processes and belief system. Additionally, the LIC 602A form notes that (R#1) is confused and disoriented. LPA Iniguez also reviewed (R#1)’s current medication list, which includes a prescription for Haloperidol 50 mg to be administered every morning. This medication is associated with the management of (R#1)’s diagnosed mental health condition. Furthermore, LPA Iniguez reviewed (R#1)’s Appraisal/Needs and Services Plan (LIC 625), dated September 24, 2025, which states that the facility is responsible for monitoring R#1 throughout the day for any physical or mental changes.

On December 11, 2025, during an interview, the facility administrator (A#1) she stated that upon being notified of (R#1)’s allegation of sexual abuse by their mental health case manager, the facility took immediate action by assessing (R#1) and offering to relocate them to a different room once one becomes available. (A#1) also indicated that the Long-Term Care Ombudsman would be informed of the incident. To ensure (R#1)’s safety, the facility implemented a two-hour wellness check protocol, with staff monitoring (R#1) throughout the day and night for any physical or mental changes. In addition, (A#1) stated that in response to the allegation, the facility followed its internal abuse protocols by interviewing relevant parties, documenting the incident, and notifying Licensing, the Ombudsman, the mental health case manager, and (R#1)’s psychiatrist. The facility does not utilize in-room surveillance cameras due to resident privacy rights, which align with regulatory standards.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20251205101712
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: 12/11/2025
NARRATIVE
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On December 11, 2025, at approximately 1:00 pm, during an interview with (W#1), (W#1) explained that when a report of sexual abuse is made by a client participating in the program, the department follows a specific protocol to ensure the client's safety and well-being. This includes offering immediate access to medical care and mental health support services tailored to the client's needs. (W#1) further stated that the department is responsible for formally reporting the incident to the appropriate authorities and initiating a thorough investigation to determine the facts and ensure accountability. These steps are taken to protect the client and uphold the program's integrity.

On December 11, 2025, at approximately 11:00 am, during an interview with (R#1), they stated that the alleged incidents occurred approximately 15 times over a period of three months. When asked whether the incidents were reported to facility staff immediately after they occurred, (R#1) stated that they did not report them at the time because they believed the behavior would stop on its own. In addition, (R#1) stated that since the report was made, (R#1) indicated that the facility has “placed a camera in their room” to monitor their safety. When asked if they currently feel safe living at the facility, (R#1) responded affirmatively, stating that they do feel safe now.

On December 11, 2025, at approximately 11:20 am, during an interview with (R#2), they stated that they do not engage in conversation with (R#1) and simply share the room for sleeping purposes. Also, (R#2) reported no knowledge of any concerns or complaints made against them by either their roommate (R#1) or facility staff. In addition, in response to the allegation of inappropriate physical contact involving (R#1), (R#2) firmly stated that they have never touched (R#1) in a sexual or harmful way and that they always maintain respectful and appropriate behavior toward them. When asked whether they feel safe living at the facility, the individual responded affirmatively.

Evaluation Report continues LIC 9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20251205101712
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: 12/11/2025
NARRATIVE
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On December 11, 2025, at approximately 11:30 am, during interviews with residents (R#3-R#10), (8) out of (8) stated that the facility consistently responds in a positive manner when asked about the facility’s response to resident concerns regarding safety, privacy, or personal well-being and, they affirmed that staff respond appropriately to both serious concerns and minor requests for assistance, based on their personal observations. In addition, (8) out of (8) residents stated that they have not observed or heard of any concerning incidents involving (R#1) and their roommate (R#2), and they feel safe living here.

During this investigation, LPA did not find sufficient evidence to support the above-mentioned allegation(s).

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation(s) are found to be UNSUBSTANTIATED.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

An exit interview was conducted, and a copy of the Complaint Report was given to Ginger Enriquez/ Facility Administrator.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4