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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602370
Report Date: 07/22/2026
Date Signed: 07/22/2026 11:34:30 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
06/29/2026 and conducted by Evaluator Perry Scott
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20260629130547
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:138; 138CENSUS: 60DATE:
07/22/2026
UNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Robin CulverTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Lack of care and supervision resident is left unattended.
Staff do not ensure provision of care and supervision to meet client needs.
Staff did not report incidents to family.
Staff shove food into resident mouth.
INVESTIGATION FINDINGS:
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*This report supersedes the report dated 07/01/2026 to add additional information and interviews.*

On 7/01/26, the department conducted an initial complaint visit to the facility and was greeted by Memory Care Coordinator, Sandy Iraheta, and Robin Culver, Executive Director. The department explained the purpose of this visit was to gather information about the complaint, gather facility files, interview staff, and deliver findings for the allegations mentioned above.

The investigation consisted of the following: On 7/22/26, the department conducted a subsequent visit the facility to interview residents about the complaint. The department investigated the allegations mentioned in this complaint and conducted interviews with staff (S1-S5) and residents (R2-R6). The department received the following documents: Resident Roster (Date: No Date), Staff Roster (Dated: 06/18/2026), ID Emergency Information (Dated:12/02/2024), Physician’s Report (Dated:10/23/2025), Service Plan (Dated: 02/06/2026), Resident Assessment (Dated: 02/06/2026), Death Report (Dated: 03/25/2026), and Preplacement Appraisal (Dated: 12/02/2024) from the facility.

Report Continued On LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2026
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 5
Control Number 11-AS-20260629130547
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: 07/22/2026
NARRATIVE
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Allegation#2-Staff do not ensure provision of care and supervision to meet client needs.

The details of the complaint alleged that the facility’s staff shoves food into the residents’ mouth, then walks away and leaves them unsupervised. It was reported that the resident chokes while eating because staff is not there to monitor the resident. On 7/01/2026, from 1:40pm-4:00pm, the department interviewed staff (S1-S5) and on 7/22/2026 from 10:00am-11:00am the department interviewed residents (R2-R6) regarding the allegation. R1 could not be interviewed because the resident has passed away. 5 of 5 staff denied the allegation that Staff do not ensure provision of care and supervision to meet client needs. All of the staff stated that they have not witnessed or heard of any staff member shoving food into (R1s) mouth and then leaving them unsupervised and to choke on their food. Staff stated that (R1) needed full assistance with eating and meal support and that a caregiver was with (R1) at all times while they were eating and that the resident has never choked on their food.

The department interviewed residents (R2-R6) about the allegation and 5 of 5 residents that were interviewed stated that the staff does ensure provision of care and supervision is provided. When asked if staff provides you with the provision of care and supervision to meet your needs, they all stated yes.

The department did not observe any incident reports of choking for (R1).

The department reviewed the Resident Assessment (Dated: 02/06/2026), and Service Plan (Dated: 02/06/2026) and observed that the resident did need full assistance with eating and meal support. The department interviewed 5 of 5 staff and all denied that the resident was ever left alone and had no knowledge of (R1) choking on their food.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff do not ensure provision of care and supervision to meet client needs. 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 did not report incidents to family.

The details of the complaint alleged that the facility staff did not report choking incidents to the family involving the resident. It was reported that the resident chokes while eating because staff is not there to monitor the resident. On 7/01/2026, from 1:40pm-4:00pm, the department interviewed staff (S1-S5) and on 7/22/2026 from 10:00am-11:00am the department interviewed residents (R2-R6) regarding the allegation.

Report Continued On LIC9099-C

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

DATE: 07/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20260629130547
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: 07/22/2026
NARRATIVE
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The investigation revealed the following: Allegation#1- Lack of care and supervision resident is left unattended.

The details of the complaint alleged that the facility’s staff leaves the resident (R1) unsupervised in the dining area when they need full assistance with feeding and mealtime support. It was reported that staff wheels the resident (R1) into the dining room and leaves them unsupervised while eating. On 7/01/2026, from 1:40pm-4:00pm, the department interviewed staff (S1-S5) and on 7/22/2026 from 10:00am-11:00am the department interviewed residents (R2-R6) regarding the allegation. R1 could not be interviewed because the resident has passed away. 5 of 5 staff denied the allegation that Lack of care and supervision resident is left unattended. All of the staff stated that the resident did need full assistance with feeding and meal support. Staff further stated that the resident was never left unattended and that there is always a caregiver available for those residents who need to be monitored while eating.

The department reviewed the Service Plan (Dated: 02/06/2026), Physician’s Report (Dated:10/23/2025), Resident Assessment (Dated: 02/06/2026), and observed that the resident did need full assistance with eating and meal support. The department interviewed 5 of 5 staff and all staff stated that (R1) was never alone while eating and full assistance and meal support was given at all times.

The department interviewed residents (R2-R6) ) about the allegation and 5 of 5 residents that were interviewed denied that due to lack of care and supervision they have been left unattended. When asked if staff has ever left you unattended for long periods of time or if you have witnessed staff leaving other residents unattended for long periods of time when they needed care and supervision, they stated no.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Lack of care and supervision resident is left unattended. 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: 07/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20260629130547
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: 07/22/2026
NARRATIVE
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R1 could not be interviewed because the resident has passed away. 5 of 5 staff denied the allegation that Staff did not report incidents to family. All staff stated that there has never been any incidents of the resident choking. Staff also stated that the family was always notified of any incidents involving (R1) and their care at the facility. But added that there was not a report of the resident choking because they have no knowledge of the incident, therefore a report was never sent to the family.

The department interviewed residents (R2-R6) about the allegation and 5 of 5 residents that were interviewed stated that the staff does report incidents to their doctor and family.

The department did not observe any incident reports of choking for (R1).

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Staff did not report incidents to family. 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 shove food into resident mouth.



The details of the complaint alleged that the facility staff shove food into the residents’ (R1) mouth and leaves without making sure the resident swallows their food. It was reported that the resident was having a hard time breathing because their mouth was stuffed with food. On 7/01/2026, from 1:40pm-4:00pm, the department interviewed staff (S1-S5) and on 7/22/2026 from 10:00am-11:00am the department interviewed residents (R2-R6) regarding the allegation. R1 could not be interviewed because the resident has passed away. 5 of 5 staff denied the allegation that Staff shove food into resident mouth. All of the staff stated that the staff has never shoved food into (R1s) mouth and never observed the resident having a hard time breathing because their mouth was full of food. Staff stated that (R1) needed full assistance with eating and mealtime support and that a caregiver was always present when they were eating.

The department interviewed residents (R2-R6) about the allegation and 5 of 5 residents that were interviewed stated that they have never witnessed staff shoving food into a resident’s mouth.

The department did not observe any incident reports of (R1) having breathing problems because of food related issues.

Report Continued On LIC9099-C

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

DATE: 07/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20260629130547
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: 07/22/2026
NARRATIVE
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Based on interviews, there is insufficient evidence to support the allegation that Staff shove food into resident mouth. 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 deficiencies were found and no citations were issued for this complaint investigation.

An exit interview was conducted with Robin Culver, Executive 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: 07/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5