191601613-6-4-2026-11-AS-PMAA-DVBMF8-20260623093355

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191601613
Report Date: 06/04/2026
Date Signed: 06/04/2026 12:00:45 PM

Substantiated

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
04/07/2026 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 11-AS-20260407130155

FACILITY NAME:	WILMINGTON GARDENS		FACILITY NUMBER:	191601613
ADMINISTRATOR:	FLORES,V.ANDT.		FACILITY TYPE:	735
ADDRESS:	1311 WEST ANAHEIM STREET		TELEPHONE:	(310) 835-6366
CITY:	WILMINGTON	STATE: CA	ZIP CODE:	90744
CAPACITY:	48; 48	CENSUS: 41	DATE:	06/04/2026
		UNANNOUNCED	TIME BEGAN:	09:32 AM
MET WITH:	Victorio Jun Flores		TIME COMPLETED:	12:01 PM

ALLEGATION(S):

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Uncleared adult is supervising clients.
Staff do not ensure facility is free of bed bugs.

INVESTIGATION FINDINGS:

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On 06/04/26 Licensing Program Analyst (LPA) Villegas conducted a subsequent complaint visit to deliver complaint findings for the above allegation(s). LPA met with Victorio Jun Flores as the purpose of today’s visit was explained.

The investigation consisted of the following: On 04/15/26 LPA Villegas obtained copies of the staff and client rosters, staff shift duties, Orkin service report and invoice dated: 03/31/26, Orkin K9 bed bug division report and invoice dated 03/20/26, and a copy of the house rules. On 04/15/26 from 10:00 am- 11:00 am LPA conducted Interviews with Staff #1-5 (S1-S5), and from 11am- 12 pm LPA conducted a tour of the facility and observed lunch service. On 04/15/25 from 1pm- 2:30 pm interviews were conducted with clients # 1-6 (C1-C6). On 05/20/26 LPA received a copy of caregiver contract dated: 08/22/25, and on 05/26/26 LPA received Orkin K9 bed bug division report dated: 04/21/26, invoices for bed bug treatment products, and steam cleaner.

The investigation revealed the following:

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026

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 8

Control Number 11-AS-20260407130155

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: WILMINGTON GARDENS	FACILITY NUMBER: 191601613
	VISIT DATE: 06/04/2026

NARRATIVE

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Allegation: An Uncleared adult is supervising clients.

It is alleged an un-fingerprint cleared female has been working at the facility for months. On 04/15/26 from 10:00 am- 11:00 am LPA conducted Interviews with S1-S5 regarding the allegation above. 5 out of 5 staff interviewed confirmed the above allegation. Additionally, during interview with S1, S1 reported that un-fingerprinted adult is contracted by the Licensee and this adult cannot leave the Licensees side or be alone in any of the resident’s bedrooms. Furthermore, S1 reports that the un-fingerprinted adult was contracted to help facility staff clen better, and contracted person is not alone in bedrooms as they are always accompanied by facility staff. On 04/15/25 from 1pm- 2:30 pm interviews were conducted with C1-C6 regarding the allegation above. 4 of the 6 clients interviewed confirmed the allegation above, 2 of the 6 clients interviewed reported having no knowledge of the allegation above. On 05/20/26 LPA received a copy of caregiver contract dated: 08/22/25, per contract uncleared staff will assist clients with activities of daily living (ADLs), monitor behaviors, provide medication reminders, and will have access to confidential information relating to clients, business operations, medical or behavioral information, and financial records. Additionally, contract section 12 reads that employment may be contingent upon criminal background clearance, TB testing, licensing requirements, required training certifications, and health screening. On 04/16/26 and 06/04/26 LPA conducted a review of staff roster and facilities staff association; LPA did not observe the adult in question to be fingerprint cleared or associated with the facility.

Allegation: Staff do not ensure facility is free of bed bugs.

It is alleged that staff are not properly fumigating, replacing mattresses, or adequately addressing the bed bugs at the facility. On 04/15/26 from 10:00 am - 11:00 am LPA conducted Interviews with S1-S5 regarding the allegation above. 4 of the 5 staff interviewed confirmed the above allegation and reported that facility staff are put in charge of treating bedbugs instead of professionals coming to service the facility. 1 of 5 staff interviewed confirmed the allegation above, however, reports that the facility has a documented plan and service quote with Orkin pest control. On 04/15/25 from 1pm- 2:30 pm interviews were conducted with C1-C6 regarding the allegation above. 1 of the 6 clients interviewed being unaware of the allegation above, 2 of the 6 clients interviewed reported there were bedbugs at the facility in the past, 2 of the 6 clients interviewed denied the allegation above, 1 of the 6 clients interviewed confirmed the allegation above and reported having bed bugs in their bedroom. 5 of the 6 clients interviewed reported that facility staff are the ones treating the bedbugs. 1

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 8

Control Number 11-AS-20260407130155

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: WILMINGTON GARDENS	FACILITY NUMBER: 191601613
	VISIT DATE: 06/04/2026

NARRATIVE

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of the 6 clients interviewed reported that a professional has treated the facility for bedbugs. On 06/02/26 LPA conducted a review of Orkin service report and invoice dated: 03/31/26, Orkin K9 bed bug division report and invoice dated 03/20/26, and Orkin K9 bed bug division report dated: 04/21/26. Per latest Orkin K9 bed bug division report dated 04/21/26, live bed bugs were verified in (4) client bedrooms. Additionally, per documented communication with S1, S1 stated that after reviewing the quotations from Orkin, the facility has concluded that the facility can manage the bed bug situation more effectively internally.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division (6) and Chapter (1) are being cited on the attached LIC 9099D.

Exit interview conducted. appeal rights explained, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026

LIC9099 (FAS) - (06/04)

Page: 6 of 8

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
04/07/2026 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 11-AS-20260407130155

FACILITY NAME:	WILMINGTON GARDENS		FACILITY NUMBER:	191601613
ADMINISTRATOR:	FLORES,V.ANDT.		FACILITY TYPE:	735
ADDRESS:	1311 WEST ANAHEIM STREET		TELEPHONE:	(310) 835-6366
CITY:	WILMINGTON	STATE: CA	ZIP CODE:	90744
CAPACITY:	48; 48	CENSUS: 41	DATE:	06/04/2026
		UNANNOUNCED	TIME BEGAN:	09:32 AM
MET WITH:	Victorio Jun Flores		TIME COMPLETED:	12:01 PM

ALLEGATION(S):

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Staff yell at clients.
Staff do not treat clients with dignity and respect.
Staff do not ensure that clients’ personal belongings are kept safe.
Staff inappropriately touched client.
Staff have inappropriate relations with clients.
Staff do not ensure clients are provided nutritious meals.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 8

Control Number 11-AS-20260407130155

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: WILMINGTON GARDENS	FACILITY NUMBER: 191601613
	VISIT DATE: 06/04/2026

NARRATIVE

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Allegation: Staff yell at clients.

It is alleged that staff members shout demands and threaten clients with fines.

On 04/15/26 from 10:00 am - 11:00 am LPA conducted Interviews with S1-S5 regarding the allegation above. 4 of 5 staff interviewed denied the allegation above. 1 of the 5 staff interviewed confirmed the allegation above and reported that clients are yelled at when they are doing something wrong. Additionally, 2 of the 5 staff interviewed reported that they are unaware if clients are threatened with fines, 2 of the 5 staff interviewed confirmed that clients are given fines, 1 of the 5 staff interviewed reported that clients are not given fines yet. On 04/15/25 from 1pm- 2:30 pm interviews were conducted with C1-C6 regarding the allegation above. 5 of the 6 clients interviewed denied the allegation above, 1 of the 6 clients interviewed confirmed the allegation above and reported that staff have called them “stupid.”

Allegation: Staff do not treat clients with dignity and respect.

It is alleged that clients in care are not treated with dignity and respect. On 04/15/26 from 10:00 am - 11:00 am LPA conducted Interviews with S1-S5 regarding the allegation above. 5 of the 5 staff interviewed denied the allegation above. On 04/15/25 from 1pm- 2:30 pm interviews were conducted with C1-C6 regarding the allegation above. 5 of the 6 clients interviewed denied the allegation above, 1 of the 6 clients interviewed confirmed the allegation above and reported that all facility staff treat them badly.

Allegation: Staff do not ensure that clients’ personal belongings are kept safe.

It is alleged that facility staff are discarding clients’ personal clothing and belongings. On 04/15/26 from 10:00 am - 11:00 am LPA conducted Interviews with S1-S5 regarding the allegation above. 2 of the 5 staff interviewed denied the allegation above, 1 of the 5 staff interviewed reporting having no knowledge of the allegation above, 2 of the 5 staff interviewed confirmed the allegation above and reported that some client belongings were discarded during deep cleaning. 3 of 5 staff interviewed reported that clients are reminded to keep their bedroom doors closed, 1 of 5 staff interviewed reported the facility is doing nothing to ensure client belongings are kept safe, 1 of 5 staff interviewed reported being unaware of what the facility is doing nothing to ensure client belongings are kept safe. On 04/15/25 from 1pm- 2:30 pm interviews were conducted with C1-C6 regarding the allegation above. 4 of the 6 clients interviewed denied the allegation above and reported that their bedroom doors are locked to keep their belongings safe. 2 of the 6 clients interviewed confirmed the allegation above and reported that nothing is being done to ensure their belongings are kept safe.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 8

Control Number 11-AS-20260407130155

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: WILMINGTON GARDENS	FACILITY NUMBER: 191601613
	VISIT DATE: 06/04/2026

NARRATIVE

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Allegation: Staff inappropriately touched client.

It is alleged that there are inappropriate personal relationships between staff multiple clients in care. On 04/15/26 from 10:00 am - 11:00 am LPA conducted Interviews with S1-S5 regarding the allegation above. 3 of the 5 staff interviewed denied the above allegation. 1 of the 5 staff interviewed denied observing any inappropriate personal relationship but has heard talks about the allegation above around the facility. 1 of the 5 staff interviewed confirmed the allegation above and reports observing flirting between staff and clients in care. 04/15/25 from 1pm- 2:30 pm interviews were conducted with C1-C6 regarding the allegation above. 5 of the 6 clients interviewed denied the allegation above, 1 of the 6 clients interviewed confirmed the allegation above and reported being called endearing names by staff. On 04/16/26 LPA conducted a review of staff roster; LPA did not observe the name of the staff who is allegedly using endearing names towards client in care.

Allegation: Staff do not ensure clients are provided with nutritious meals.

It is alleged that staff are reducing protein portions by half and are adding more potatoes to meals to cut costs. On 04/15/26 from 10:00 am - 11:00 am LPA conducted Interviews with S1-S5 regarding the allegation above. 3 of the 5 staff interviewed denied the allegation above and report there are no issues with potions being provided, 2 of the 5 staff interviewed confirmed the allegation above and report portions have gotten smaller and there are more vegetables than protein provided. Additionally, 4 of the 5 staff interviewed report that a second serving is provided when requested by a client. 1 of the 5 staff interviewed reported that since portions have gotten smaller, a second serving is not provided when requested by client in care. 04/15/25 from 1pm- 2:30 pm interviews were conducted with C1-C6 regarding the allegation above. 4 of the 6 clients interviewed denied the above allegation and have no concerns about the meals being provided. 2 of the 6 clients interviewed confirmed the allegation above and reported that meals provided are unhealthy and at times look like they have been spat on. 04/15/26 LPA observed lunch service, LPA observed clients to be served a ham and cheese sandwich, peaches, and a bowl of soup.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 8

Control Number 11-AS-20260407130155

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: WILMINGTON GARDENS	FACILITY NUMBER: 191601613
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/04/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/25/2026 Section Cited CCR 80087(a)	1 2 3 4 5 6 7	80087 Buildings and Grounds (a)The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. This requirement is not met as evidence by: the licensee did not comply with the secition cited above as there are bed bugs at the	1 2 3 4 5 6 7	Licensee and Administrator to review regualtion cited, and self report the understanding of the title 22 regulation. LPA to recevice by POC due date a detail plan on how the facility will get into compliance.
	8 9 10 11 12 13 14	facility. Licensee and Administrator has opt out of pest control services and reported that the facility can manage the bed bug situation more effectively internally, however bed bugs are still present which poses/posed a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 11-AS-20260407130155

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: WILMINGTON GARDENS	FACILITY NUMBER: 191601613
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/04/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/05/2026 Section Cited CCR 80019(e)(2)	1 2 3 4 5 6 7	80019 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1522 shall prior to working, residing or volunteering in a licensed facility:(2) Obtain a California clearance or a criminal record exemption as required by the Department or	1 2 3 4 5 6 7	Licensee and Administrator to remove staff #6 (S6) from schedule until finger print clearance is obtained. An employee file for (S6) shall be created and maintained at the facility. Regulation to be reviewed in order to get into compliance, Licensee and Adminsitrator to self certified that regulation has been reviewed and is understood.
	8 9 10 11 12 13 14	This requirement is not met as evidence by: there is an unfingerprinted staff (S6) working at the facility who according to their caregiver contract dated: 08/22/25 (S6) will be assisting clients with activities of dailiy living which poses/posed an immidiate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 06/04/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2026

LIC9099 (FAS) - (06/04)

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