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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602370
Report Date: 03/13/2026
Date Signed: 03/13/2026 11:43:28 AM

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
01/30/2026 and conducted by Evaluator Perry Scott
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20260130115632
FACILITY NAME:PINNACLES AT BURTON, THEFACILITY NUMBER:
197602370
ADMINISTRATOR:ROBIN CULVERFACILITY TYPE:
740
ADDRESS:8757 BURTON WAYTELEPHONE:
(310) 278-8323
CITY:LOS ANGELESSTATE: CAZIP CODE:
90048
CAPACITY:138CENSUS: 50DATE:
03/13/2026
UNANNOUNCEDTIME BEGAN:
10:09 AM
MET WITH:Sandy IrahetaTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not prevent resident from developing pressure injuries.
Staff do not ensure that residents’ incontinent care needs are met.
Staff do not assist resident with eating.
Staff do not assist resident with ambulation.
Staff do not observe resident for change in condition.
Staff are not following resident's care plan.
Staff do not report incidents to appropriate parties.
Licensee does not ensure that staff have required training.
INVESTIGATION FINDINGS:
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On 03/13/2026, the department conducted an unannounced subsequent complaint investigation visit to deliver findings for the allegations listed above. LPA met with Memory Care Coordinator, Sandy Iraheta, and was granted access into the facility.

The investigation consisted of the following: On 2/6/26, at 9:30am, the department conducted an initial complaint visit to the facility and was greeted by Sandy Iraheta, Memory Care Director. The department explained the purpose of this visit was to gather information about the complaint, gather facility files, and interview staff and residents.

The department investigated the allegations mentioned in this complaint and conducted interviews with staff (S1-S4) and residents (R1-R6). The department received the following documents: Resident Roster (Date: No Date), Staff Roster (Dated: 01/31/2026), Resident Notes (06/23/2025-02/05/2026)...

Report Continued On LIC909-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2026
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 7
Control Number 11-AS-20260130115632
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: PINNACLES AT BURTON, THE
FACILITY NUMBER: 197602370
VISIT DATE: 03/13/2026
NARRATIVE
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Face Sheet/ID Emergency Information (Dated: 02/26/2026), Resident Lease Agreement (Dated: 06/05/2025), Addendum Note (Dated:02/13/2025), Feeding Abilities Note (Dated: 12/05/2025), Physician’s Report (Dated: 10/23/2025), Service Plan (Dated: 01/08/2026), Physician Orders for Life Sustaining Treatment (Dated: 09/15/2024), Caregiver Daily Log Notes (Dated:02/02/26, 02/03/26, 02/04/26), In-Service Training (Dated: 2025), and Resident Assessment (Dated: 02/06/2026) from the facility.

The investigation revealed the following: Allegation #1- Staff did not prevent resident from developing pressure injuries.



The details of the complaint alleged that the facility staff did not prevent the resident (R1) from developing pressure injuries. It was reported that R1 developed pressure injuries in their groin and thigh areas because staff leave R1 in soiled diapers for extended periods of time, staff do not rotate R1 or ambulate R1. On 2/6/2026, from 9:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R6) regarding the allegation. R1 could not be interviewed due to cognitive impairment issues. 4 of 4 staff denied the allegation that Staff did not prevent resident from developing pressure injuries. All staff stated that R1 is not being treated for wound care for pressure injuries. They stated that to their knowledge R1 does not have any pressure injuries. They also stated that R1 is receiving two-person full assistance with bathing, dressing, toileting, mobility support, and repositioning every two hours to prevent bedsores and does not have any pressure injuries. They also state that R1 is assisted with ambulation, changed regularly, and does not sit in soiled diapers for extended periods of time.

The department interviewed residents (R1-R6) about the allegation and 5 of 6 residents that were interviewed stated that they have not developed any pressure injuries due to neglect from the staff. They also stated that the staff are attentive to their needs and are happy with the care and supervision that is given by the staff.

The department reviewed the Physician’s Report (Dated: 10/23/2025), Service Plan (Dated: 01/08/2026), Resident Assessment (Dated: 02/06/2026), Caregiver Daily Log Notes (Dated:02/02/26, 02/03/26, 02/04/26), and Face Sheet/ID Emergency Information (Dated: 02/26/2026) and did not observe any evidence of pressure injuries noted for R1.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff did not prevent resident from developing pressure injuries. 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.

Report Continued On LIC9099-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 11-AS-20260130115632
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: PINNACLES AT BURTON, THE
FACILITY NUMBER: 197602370
VISIT DATE: 03/13/2026
NARRATIVE
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Allegation #2- Staff do not ensure that residents’ incontinent care needs are met.

The details of the complaint alleged that the facility staff do not ensure R1’s incontinent care needs are met. It was reported that the facility staff leave R1 in soiled diapers for extended periods of time. On 2/6/2026, from 9:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R6) regarding the allegation. R1 could not be interviewed due to cognitive impairment issues. 4 of 4 staff denied the allegation that Staff do not ensure that residents’ incontinent care needs are met. All staff stated that the allegation was not true and they have never left R1 in soiled briefs for an extended period of time. They state that all residents who are incontinent are checked on and changed every two hours or more depending on the resident and their care needs.

The department interviewed residents (R1-R6) about the allegation and 5 of 6 residents that were interviewed stated that their incontinent needs are being met timely by the staff and have no complaints.

The department reviewed the Service Plan (Dated: 01/08/2026), Caregiver Daily Log Notes (Dated:02/02/26, 02/03/26, 02/04/26), and the Physician’s Report (Dated: 10/23/2025) and did not observe any lack in care or assistance in incontinence care.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff do not ensure that residents’ incontinent care needs are met. 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.
Allegation #3- Staff do not assist resident with eating.

The details of the complaint alleged that the facility staff do not assist R1 with eating. It was reported that R1 chokes while eating because staff shoves food into R1’s mouth, then walks away and leaves R1 unsupervised. On 2/6/2026, from 9:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R6) regarding the allegation. R1 could not be interviewed due to cognitive impairment issues. 4 of 4 staff denied the allegation Staff do not assist resident with eating. All staff stated that they do assist the resident with eating and it is in R1s service plan for full assistance with feeding and mealtime support. However, they state the family tells them it would be beneficial if R1 was able to feed R1s self. They stated that the family stressed that R1 be given utensils and allowed R1 to feed themselves.



The department interviewed residents (R1-R6) about the allegation and 5 of 6 residents that were interviewed stated that they do not need assistance with eating.

Report Continued On LIC9099-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 11-AS-20260130115632
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: PINNACLES AT BURTON, THE
FACILITY NUMBER: 197602370
VISIT DATE: 03/13/2026
NARRATIVE
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The department reviewed the Service Plan (Dated: 01/08/2026), Caregiver Daily Log Notes (Dated:02/02/26, 02/03/26, 02/04/26), Resident Notes (06/23/2025-02/05/2026), Feeding Abilities Note (Dated: 12/05/2025), and Physician’s Report (Dated: 10/23/2025) and observed that there was communication between the facility and the family encouraging independence on the part of R1 to feed themselves. The department also observed that the Physician’s report states that the resident is able to feed themselves.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff do not assist resident with eating. 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.

Allegation #4- Staff do not assist resident with ambulation.

The details of the complaint alleged that the facility staff do not rotate or assist R1 with ambulation. It was reported that staff do not turn or reposition R1 causing pressure injuries. On 2/6/2026, from 9:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R6) regarding the allegation. R1 could not be interviewed due to cognitive impairment issues. 4 of 4 staff denied the allegation Staff do not assist resident with ambulation. All staff stated that it was not true. They stated that they transfer R1 from their bed to their wheelchair and assist with Activities of Daily Living every day. All staff further stated that they follow R1s service plan which includes full assistance with bathing, dressing, grooming, toileting, transfer, and mobility.



The department interviewed residents (R1-R6) about the allegation and 5 of 6 residents that were interviewed stated that they do not need assistance with ambulation but are confident that staff would assist them if they were needed.

The department reviewed the Physician’s Report (Dated: 10/23/2025), Service Plan (Dated: 01/08/2026), Caregiver Daily Log Notes (Dated:02/02/26, 02/03/26, 02/04/26), and Resident Assessment (Dated: 02/06/2026) and did not find any evidence that the facility was not adhering to the service plan.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff do not assist resident with ambulation. 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.


Report Continued On LIC9099-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 11-AS-20260130115632
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: PINNACLES AT BURTON, THE
FACILITY NUMBER: 197602370
VISIT DATE: 03/13/2026
NARRATIVE
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Allegation #5- Staff do not observe resident for change in condition.

The details of the complaint alleged that the facility staff do not observe changes in R1’s condition. It was reported that R1 had a fever, low oxygen level and that R1 couldn't breathe. During the incident, a witness observed R1 having food shoved into R1’s mouth and R1 was having a hard time breathing but staff did not notice any of the changes in R1’s condition. On 2/6/2026, from 9:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R6) regarding the allegation. R1 could not be interviewed due to cognitive impairment issues. 4 of 4 staff denied the allegation Staff do not observe resident for change in condition. All staff stated that they are all trained to notice changes in a resident’s condition and would act accordingly if changes were noticed. 4 out of 4 staff stated that R1 has not had any incidents of choking or were aware of any to their knowledge.



The department interviewed residents (R1-R6) about the allegation and 5 of 6 residents that were interviewed stated that they were confident that staff would notice if they had a change in condition.

The department reviewed the Physician’s Report (Dated: 10/23/2025), Service Plan (Dated: 01/08/2026), and Resident Assessment (Dated: 02/06/2026) and did not observe any incidents or observations that the resident was at risk for choking or has had a change in condition.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff do not observe resident for change in condition. 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.
Allegation #6- Staff are not following resident's care plan.

The details of the complaint alleged that the facility staff are not following R1’s care plan. It was reported that R1 has a care plan regarding the placement and cleaning of R1’s dentures. However, staff are not correctly putting R1’s dentures into R1’s mouth or cleaning their dentures. On 2/6/2026, from 9:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R6) regarding the allegation. R1 could not be interviewed due to cognitive impairment issues. 4 of 4 staff denied the allegation Staff are not following resident's care plan. All staff stated that the resident does have a service plan that involves cleaning and changing R1s dentures. They all stated that they are adhering to the service plan and are in constant contact with the family about R1s dental care.



The department interviewed residents (R1-R6) about the allegation and 3 of 6 residents that were interviewed stated that they have a service plan and the staff are adhering to it. While two other residents stated they did not have a specific service plan that should be followed.

Report Continued On LIC9099-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 11-AS-20260130115632
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: PINNACLES AT BURTON, THE
FACILITY NUMBER: 197602370
VISIT DATE: 03/13/2026
NARRATIVE
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The department reviewed the Service Plan (Dated: 01/08/2026) and interviewed staff and did not observe or find any evidence that the facility did not follow the service plan.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff are not following resident's care plan. 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.

Allegation #7- Staff do not report incidents to appropriate parties.

The details of the complaint alleged that R1 choked while eating and that staff did not report the choking incidents to the family. On 2/6/2026, from 9:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R6) regarding the allegation. R1 could not be interviewed due to cognitive impairment issues. 4 of 4 staff denied the allegation Staff do not report incidents to appropriate parties. All staff stated that R1 has not had any incidents of choking at the facility to their knowledge. Staff further stated that any incidents involving the residents are reported as required by Community Care Licensing.



The department interviewed residents (R1-R6) about the allegation and 5 of 6 residents that were interviewed stated that the staff does let their responsible parties know if they have an incident in the facility.

The department reviewed the Resident Notes (06/23/2025-02/05/2026), Face Sheet/ID Emergency Information (Dated: 02/26/2026), and Caregiver Daily Log Notes (Dated:02/02/26, 02/03/26, 02/04/26) and did not observe any evidence that the resident had a choking incident or a history of choking.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff do not report incidents to appropriate parties. 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.

Allegation #8- Licensee does not ensure that staff have required training.

The details of the complaint alleged that the facility staff do not have the required training to follow R1’s care plan. It was reported that a staff member stated that they have not received proper training to assist with correctly placing R1s’ dentures in their mouth. On 2/6/2026, from 9:30am-2:00pm, the department interviewed staff (S1-S4) and residents (R1-R6) regarding the allegation. R1 could not be interviewed due to cognitive impairment issues. 4 of 4 staff denied the allegation Licensee does not ensure that staff have required training...



Report Continued On LIC9099-C
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 11-AS-20260130115632
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: PINNACLES AT BURTON, THE
FACILITY NUMBER: 197602370
VISIT DATE: 03/13/2026
NARRATIVE
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 All staff stated that they do have training in caring for R1 and in taking care of R1s dentures.

The department interviewed residents (R1-R6) about the allegation and 5 of 6 residents that were interviewed stated that they believe the staff does have sufficient training to take care of them and their service needs.

The department reviewed the In-Service Training (Dated: 2025), Resident Notes (06/23/2025-02/05/2026), and Caregiver Daily Log Notes (Dated:02/02/26, 02/03/26, 02/04/26) and observed that the facility was in contact with the family and following the request for the care of R1’s dentures as well as had other required training for the position.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Licensee does not ensure that staff have required training. 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 citations were issued for this complaint investigation.

An exit interview was conducted with Sandy Iraheta, Memory Care Director, and a hard copy of this Complaint Investigation Report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2026
LIC9099 (FAS) - (06/04)
Page: 7 of 7