Inspection Reports for
Carson Senior Assisted Living

The complaint alleged that a resident (R#1) was sexually assaulted by another resident (R#2). The investigation found no sufficient evidence to support the allegation. The facility took immediate action to ensure safety, including two-hour wellness checks and notifying the Long-Term Care Ombudsman and other relevant parties. Resident and witness interviews indicated no observed incidents and residents reported feeling safe.

The investigation included interviews with residents, staff, and review of relevant documents. The allegation was found to be unsubstantiated due to insufficient evidence, and the facility had implemented safety measures including wellness checks and notification of appropriate authorities.

The complaint alleged that a resident (R#1) was sexually assaulted by another resident (R#2). The investigation found the allegation unsubstantiated due to lack of sufficient evidence. The facility implemented safety measures including two-hour wellness checks and notification of the Ombudsman and mental health professionals. Interviews with residents and staff confirmed no observed incidents and feelings of safety.

The investigation included interviews and record reviews and found insufficient evidence to substantiate the allegation. The facility took immediate action to ensure resident safety, including wellness checks and notifying relevant authorities. Residents and involved parties reported feeling safe, and no evidence supported the claim of staff negligence.

The complaint alleged that staff failed to promptly seek medical attention for Resident #1 who was reportedly very sick with cold symptoms possibly related to COVID-19. Interviews with staff and residents did not corroborate the allegation. Staff confirmed no COVID-19 cases and that infection control measures were in place. Resident #1 was capable of self-care and only required medication assistance. The allegation was found unsubstantiated.

The investigation found no evidence to support the allegation. Interviews with staff and residents, record reviews, and observations indicated that the resident was independent, received adequate care, and no symptoms requiring immediate medical attention were observed. The allegation was unsubstantiated and no deficiencies were issued.

The complaint alleged that staff wrongfully evicted a resident. The investigation included interviews with staff and residents, and review of relevant documents such as eviction notices, incident reports, and sheriff reports. The allegation was found unsubstantiated due to lack of sufficient evidence.

The investigation found insufficient evidence to substantiate the allegation of wrongful eviction. Staff and residents denied the allegation, and records showed no three-day eviction notice was provided. The allegation was deemed unsubstantiated.

The complaint alleged that staff verbally and physically abused a resident resulting in bruises and scratches. Interviews with five staff members and eight residents mostly denied the allegation. The Client Wellness Program Manager also denied the allegation and noted plans to transfer the resident to a higher level of care facility. Incident reports and photos showed no injuries. The resident was unavailable for interview due to hospitalization. The allegation was unsubstantiated due to lack of evidence.

The investigation found no evidence to support the allegation of staff physically assaulting a resident. Interviews with staff and residents denied the allegation, and incident reports and photos showed no injuries. The allegation was determined to be unsubstantiated.

All client records were complete and staff records were incomplete, but no discrepancies or deficiencies were observed during the visit. No deficiencies were cited.

The facility was found to be in compliance with no deficiencies cited during the time of the visit. The physical plant, resident rooms, records, disaster plan, kitchen, and infection control practices were all inspected and found satisfactory.

The complaint alleged that staff did not prevent residents from engaging in physical altercation, specifically that Resident #1 was repeatedly hit on the back of the head by Resident #2. Interviews with residents, staff, and a family representative found no evidence of physical altercations, and the allegation was unsubstantiated.

The investigation found no evidence to support the allegation of physical altercations between residents. Interviews with residents, staff, and a family witness did not corroborate the complaint, and the allegation was determined to be unsubstantiated.

The complaint involved three allegations: 1) Resident sustained unexplained bruising while in care; 2) Facility staff did not seek medical attention in a timely manner; 3) Facility staff did not allow resident visitation. After interviews, record reviews, and observations, all allegations were found unsubstantiated due to lack of evidence.

The investigation found no evidence to support the allegations. Resident #1's bruising was linked to medication side effects and no neglect was found. Medical attention was provided timely, and visitation was not denied as alleged.

The complaint alleged that staff did not allow a resident to manage their own funds and did not safeguard the resident's finances. The resident claimed the administrator was taking money from their bank account without written authorization. The facility was designated as the representative payee by Social Security. After investigation, the allegations were found to be unsubstantiated due to lack of sufficient evidence.

The investigation found insufficient evidence to substantiate the allegations. Interviews with residents, staff, and the administrator, as well as document reviews, indicated that the facility manages some residents' finances as authorized by Social Security, and no evidence of financial mismanagement or physical harm was found.

The complaint alleged that facility staff withheld residents' medications, which resulted in hospitalization. After reviewing records and conducting interviews, the allegation was found to be unsubstantiated.

The investigation found no discrepancies in medication administration records and interviews with residents, staff, and the administrator confirmed that medications were given as prescribed. The allegation was found to be unsubstantiated due to insufficient evidence.

The complaint investigation was triggered by allegations that staff did not ensure dentures and clothes were clean, neglected resident causing pressure injuries, failed to safeguard personal property, did not contact authorized representatives when resident became unresponsive, and did not notice changes in resident condition. The investigation included interviews with staff, family, residents, and hospice personnel, and review of medical and care records. The allegations were found unsubstantiated.

The investigation reviewed multiple allegations including failure to clean dentures, clothing cleanliness, pressure injury neglect, safeguarding personal property, contacting authorized representatives, and noticing changes in resident condition. After interviews, record reviews, and evidence collection, the allegations were found to be unsubstantiated due to insufficient evidence.

The complaint alleged staff neglected resident R1, withheld medication from R1, and did not respond timely to R1's call assistance button. The investigation included interviews with staff, residents, and a witness, and review of medical and incident records. The allegations were found unsubstantiated.

The investigation found the allegations unsubstantiated based on interviews, observations, and review of supporting documentation. Staff and most residents denied the allegations, and no errors were found in medication administration records.

The complaint alleged illegal eviction of a resident. The investigation included interviews with the resident, staff, administrator, and witnesses, as well as review of incident reports and resident records. The allegation was found unsubstantiated due to lack of evidence.

The investigation found no evidence to support the allegation of illegal eviction. Interviews, record reviews, and observations confirmed the resident remained at the facility with personal belongings intact and no formal eviction notice was issued. The allegation was determined to be unsubstantiated.

The facility was found to be in good condition with no deficiencies noted. All safety equipment was operational, infection control practices were observed, and records were maintained accurately.

The complaint was unsubstantiated. Allegations included a resident sustaining a fracture due to lack of supervision and staff failing to seek timely medical attention. Interviews and record reviews did not support these allegations.

The investigation found no preponderance of evidence to support the allegations. Staff and records indicated the resident was independent and not a fall risk, and staff were unaware of the fall until the resident reported it at the hospital. No deficiencies were observed or cited.

The complaint investigation was unsubstantiated. Allegations included staff threatening a resident, failure to safeguard personal belongings, and unsafe environment claims. Interviews and evidence showed no proof of these allegations.

The investigation found no evidence to support the allegations. Interviews with residents, staff, and the administrator, as well as a review of records and a facility tour, indicated the allegations were unsubstantiated.

The complaint alleged failure to observe changes in resident #1's health and neglect of wellness checkups. The investigation found that medical and psychiatric assessments were conducted regularly, staff observed the resident every two hours, and interviews with residents, family, and staff indicated sufficient care and supervision. The allegations were unsubstantiated.

The investigation included interviews, record reviews, and facility tours, and found no evidence to support the allegations. The department concluded the allegations were unsubstantiated due to lack of preponderance of evidence.

The complaint alleged that staff neglected resident #1's care resulting in infection and that the resident fell due to staff negligence. The investigation included interviews with staff, residents, and family, review of medical and service records, and facility tours. The allegations were found unsubstantiated due to lack of evidence.

The investigation found no evidence to corroborate the allegations of neglect causing infection or of a resident fall due to staff negligence. Interviews, record reviews, and observations indicated the resident received appropriate care and supervision.

The complaint alleged the facility had pests, specifically multiple cockroaches on the wall. The investigation included interviews, facility inspection, and review of pest control services. No evidence was found to support the allegation, and it was deemed unsubstantiated.

A full inspection of the facility, interviews with residents and staff, and review of pest control contracts found no evidence of pest infestation. The allegation was determined to be unsubstantiated.

The complaint investigation was triggered by allegations that staff failed to seek medical attention for a resident with a swollen ankle, withheld the resident's personal and incidental cash resources, and neglected the resident's hygiene and laundry needs. After interviews, record reviews, and observations, the allegations were found to be unsubstantiated.

The investigation found no evidence to support the allegations. Interviews with residents, staff, and family representatives, along with reviews of medical records and facility logs, indicated that the resident received appropriate medical attention, personal and incidental funds, hygiene assistance, and laundry services. The allegations were determined to be unsubstantiated.

The complaint alleged that resident #1 sustained multiple pressure injuries while in care at the facility. The investigation included review of medical and service records, interviews with residents and staff, and facility tours. The allegation was found unsubstantiated due to lack of evidence of neglect or lack of supervision.

The investigation found no evidence to support neglect or lack of supervision related to the resident's pressure injuries. The allegation was determined to be unsubstantiated based on review of medical records, interviews, and facility inspection.

The investigation found no evidence of negligence or foul play by the facility regarding the death of resident #1, whose cause of death was cardiopulmonary arrest. The Department will now close this investigation.

The complaint alleged failure to supervise a resident who wandered away, failure to safeguard residents' cash resources, failure to administer medication as prescribed, and that the facility was not kept clean. All allegations were found unsubstantiated based on interviews, record reviews, and observations.

The investigation found no evidence to support the allegations. Resident #1 was verified to be capable of leaving the facility unassisted, financial transactions were legitimate and managed by a family representative, medication administration records were accurate and complete, and the facility was found clean and well-maintained.

The report documents the circumstances surrounding the death of resident #1, including hospital admission due to a fall and subsequent death. Interviews were conducted with staff and a resident, and relevant documents were collected.

The investigation found no evidence of negligence or foul play by the facility related to the resident's death, which was due to a drug overdose. The case is now closed.

The complaint alleged failure to provide adequate supervision to residents. The allegation was unsubstantiated due to lack of evidence. The facility reported the incident to appropriate authorities and took corrective actions.

The investigation found no evidence to support the allegation of inadequate supervision. An altercation between two residents occurred, but the facility acted appropriately by reporting the incident and separating the residents. No deficiencies were cited.

The complaint alleged that facility staff failed to provide resident records to the resident's authorized representative. The investigation revealed the request was received late and was forwarded to the facility's legal representatives. The allegation was unsubstantiated due to lack of evidence.

The investigation found insufficient evidence to support the allegation that the facility disregarded or failed to provide the requested resident service records. The allegation was determined to be unsubstantiated and no deficiencies were cited.

The complaint alleged staff were not providing resident #1's prescribed Parkinson's medications. The investigation included interviews with residents and staff, review of medication administration records, and facility inspection. The allegation was found to be unsubstantiated due to lack of evidence.

The investigation found no evidence to support the allegation that resident #1's Parkinson's medications were not provided as prescribed. Interviews, record reviews, and observations indicated medications were administered as prescribed and the allegation was unsubstantiated.

The facility reported the death of resident #1 on 09/02/2022, who was declared dead at a park in Pomona on 08/26/2022. The facility staff last saw the resident after breakfast on 08/26/2022 before the resident left for a daily outing; details of the death are under investigation and unknown at this time.

The complaint alleged that Resident #1 sustained an unexplained injury while in care and that staff failed to assist with medical care. The resident and witnesses denied the allegations, and medical records confirmed timely medical attention was provided. The allegations were found unsubstantiated.

The investigation found no evidence to support the allegations. Interviews, medical records, and observations indicated the resident was well cared for, and the injury likely occurred outside the facility. No deficiencies were cited during the visit.

The complaint alleged failure to communicate with the responsible party, failure to respond to changes in resident health, and failure to assist resident #1 with hygiene needs. The investigation included interviews with staff, residents, and witnesses, review of service records, staffing schedules, and facility logs. No evidence was found to substantiate the allegations, and the complaint was deemed unsubstantiated.

The investigation found no evidence to support the allegations. Interviews, record reviews, and observations indicated that communication with family representatives was adequate, resident care including hygiene assistance was provided as required, and staffing levels were sufficient. The allegations were determined to be unsubstantiated.

The complaint alleged that staff did not prevent a physical altercation between residents on 03/09/22. The investigation included interviews with residents and staff, review of service records, and facility observation. No evidence was found to substantiate the allegation, and the complaint was determined to be unsubstantiated.

The investigation found no evidence to support the allegation that staff failed to prevent a physical altercation between residents. Interviews, observations, and record reviews did not substantiate the complaint.

The complaint included ten allegations concerning food quality, facility cleanliness, bedding changes, activity provision, forced bed rest, bathing and diapering care, call button response times, understaffing, and physical therapy provision. After interviews, record reviews, and observations, all allegations were found unsubstantiated.

The investigation found no evidence to support any of the ten allegations made by the complainant. The facility was observed to be clean, residents' needs for bathing, diapering, call button response, activities, and physical therapy were met or appropriately managed, and staffing levels were adequate. The allegations were determined to be unsubstantiated.

The complaint included allegations that staff yelled at residents, failed to assist with hygiene, physically abused residents, and that the facility was dirty, unkept, and had cockroaches. The investigation found these allegations unsubstantiated due to lack of evidence.

The investigation found no evidence to support the allegations of staff yelling at residents, neglecting hygiene assistance, physical abuse, or poor facility cleanliness. Interviews, record reviews, and observations indicated the facility was clean and staff treated residents respectfully.

The complaint investigation was unsubstantiated. Allegations included resident falls while in care, staff not properly administering insulin, and staff not feeding the resident. Evidence did not prove or disprove the allegations.

The investigation found no preponderance of evidence to substantiate the allegations of resident falls, improper insulin administration, or staff not feeding the resident. The allegations were determined to be unsubstantiated after interviews, record reviews, and facility inspections.

The complaint alleged that resident #1's needs were not met and that the resident was left in soiled clothing for more than 24 hours. Interviews with staff, residents, and witnesses, as well as review of records and a sheriff's department report, found no evidence to support these allegations. The allegations were unsubstantiated.

The investigation included interviews, facility inspection, and record reviews, and found no sufficient evidence to support the allegations. The allegations were determined to be unsubstantiated and no deficiencies were cited.

The complaint alleged that a resident was left on the ground for approximately 1-3 hours after a fall and that resident care needs were not being met, including claims of the resident appearing unkempt and having an unpleasant smell. The investigation included interviews with staff, witnesses, and residents, inspection of the facility, and review of service records. The allegations were found unsubstantiated due to lack of sufficient evidence.

The investigation found no sufficient evidence to support the allegations. Interviews with staff, residents, and review of service records indicated that proper emergency procedures were followed and that the resident's care needs were being met. The allegations were determined to be unsubstantiated.

The complaint involved three allegations: the resident's mattress needed replacing, staff did not ensure the resident received medications, and the resident was left on the ground for an extended period after falling. After interviews, observations, and record reviews, the allegations were found unsubstantiated.

The investigation found no evidence to support the allegations that the resident's mattress needed replacing, that staff failed to ensure timely medication administration, or that a resident was left on the ground for an extended period after falling. All allegations were determined to be unsubstantiated.

The complaint alleged that staff were not meeting resident #1's hygiene needs, specifically that the resident had not been showered for a week. The investigation included interviews with staff, witnesses, and residents, review of shower schedule notes and service records, and a facility inspection. The allegation was found to be unsubstantiated due to lack of sufficient evidence.

The investigation found no sufficient evidence to support the allegation that staff failed to meet the resident's hygiene needs. Interviews, record reviews, and observations indicated the resident received bathing assistance twice weekly as scheduled.

The complaint alleged the facility lacked grab bars and hot water for resident #1. After interviews with staff, resident, witnesses, and a virtual tour, the allegations were found unsubstantiated due to insufficient evidence.

The investigation found no evidence to support the allegations. Interviews, record reviews, and a virtual tour confirmed that resident #1's room had grab bars and hot water, and the resident expressed satisfaction with care and living conditions. The allegations were determined to be unsubstantiated.