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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197602370
Report Date: 09/17/2025
Date Signed: 09/21/2025 09:10:48 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
09/09/2025 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250909091421
FACILITY NAME:PINNACLES AT BURTON, THEFACILITY NUMBER:
197602370
ADMINISTRATOR:CHANEL ANN SANCHEZFACILITY TYPE:
740
ADDRESS:8757 BURTON WAYTELEPHONE:
(310) 278-8323
CITY:LOS ANGELESSTATE: CAZIP CODE:
90048
CAPACITY:138CENSUS: 44DATE:
09/17/2025
UNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Robin Culver & Sandy IrahetaTIME COMPLETED:
02:59 PM
ALLEGATION(S):
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The facility staff failed to provide adequate supervision resulted in the resident eloping.
The facility does not have an auditory device or other staff alert feature to monitor exits.
INVESTIGATION FINDINGS:
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On September 17, 2025, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit. Robin Culver, Executive Director and Sandy Irahta Resident Coordinatorr, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegations mentioned above.

The investigation included interviews, a collection of records, and a tour of the facility. Interviews were conducted with Staff #1 through Staff #3 (S1-S3), Resident #1 (R1) and Witness #1 (W1). The Department reviewed several documents, including the Facility Resident Roster (dated 09/12/25), Facility Personnel Roster LIC 500 (dated 09/11/25 & 09/15/25), and (R1's) Physicians Report LIC 602 (dated 02/24/25), as well as other pertinent records associated with this complaint.

(Evaluation Report continues LIC 9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
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 7
Control Number 11-AS-20250909091421
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: 09/17/2025
NARRATIVE
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INVESTIGATION REVEALED FOLLOWING:

Allegation #1: The facility staff failed to provide adequate supervision resulted in the resident eloping.

The complaint alleges that the facility staff failed to provide adequate supervision for Resident #1 (R1), which led to (R1) eloping from the premises. It was reported that staff were unaware of (R1's) disappearance on September 7, 2025, until staff began checking the facility for (R1). According to the report, the Beverly Hills Fire Department discovered (R1) on the sidewalk with injuries. (R1) had a laceration on the right eyebrow and multiple skin tears on the right elbow. No additional information about this situation was provided.

On September 12, 2025, between 10:18 AM and 12:15 PM, the Department interviewed staff members identified as Staff #1 through Staff #3. Three (3) out of the three (3) staff members validated the incidents with Resident #1 (R1) eloping from the facility on September 7, and a subsequent elopement on September 8, 2025. All staff statements confirmed through the Facility End of Shift Reports (dated September 7, 2025, and September 8, 2025). (R1) exited the facility unattended by utilizing the fourth-floor exit stairwell, navigating through the main floor corridor and kitchen entry hallway, and ultimately leaving through the rear receiving/delivery service and exterior gated door into the alley. (S1) reported that (S1) only became aware of (R1's) disappearance during routine room checks. (R1) was last seen around 2:30 AM on September 7, 2025, outside the facility. According to (S1), (R1) sustained injuries during the elopement incident, having fallen and suffered injuries to the head, hand, and elbow. (R1) received medical treatment at Cedars Sinai for injuries and was discharged later that day.

(S2) reported that (R1) was unaccounted for and on September 8, 2025, between 9:30 PM and 11:30 PM, and was seen wandering outside the facility by neighboring vendors. (S2) mentioned that (R1) managed to leave the facility through the kitchen rear doors that had an egress bar with no sensory alarm in place. (S2) reported that law enforcement was notified, but later, (R1) returned to the facility on (R1's) own and was found in another resident's room on the first floor.

During evening shifts, the facility typically has three to four staff members, while night shifts are covered by only two staff members. According to (S1 and S2), they felt understaffed on the days when (R1) elopement occurred both times. Additionally, there are no surveillance cameras installed on the premises, according to (S3).

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 11-AS-20250909091421
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: 09/17/2025
NARRATIVE
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On September 12, 2025, between 11:45 AM and 12:00 PM, the Department interviewed resident identified as Resident #1 (R1). (R1) acknowledged that (R1) left the facility and sustained injuries, which required hospital treatment. While (R1) could not provide additional details about the incidents, (R1) remembered leaving the facility unattended. During the interview with (R1), noticeable injuries and visible signs of trauma on the face, elbows, and hands.

On September 12, 2025, between 12:16 PM and 12:33 PM, the Department interviewed witness identified as the power of attorney to (R1) as Witness #1 (W1). (W1) verified that facility staff notified (W1) of incidents involving (R1) by telephone communication. (W1) indicated that (R1) is medically assessed with wandering and elopement behaviors. (W1) clarified that (R1) being new to the facility is being triggered by the unfamiliar environment and may frequently attempt to leave. (W1) mentioned that during the medical assessment intake (W1) was disclosed to the facility of (R1’s) wandering behavior.

A review of Resident #1 (R1's) Physician's Report LIC 602 (dated 02/24/25), Preplacement Appraisal Information LIC 603A (dated 02/22/25), and Service Plan (dated 09/02/25) indicated that (R1) requires assistance due to memory impairment and needs special observation or night supervision due to confusion, forgetfulness, or wandering. The facility’s evaluation of (R1) in Memory Care is Level 4, which is to provide advanced care related to wandering and elopement, offering high-level, round-the-clock support. A review of (R1’s) prescribed medications indicated that (3) three out of the three (3) medications cause side effects of wandering/elopement behaviors (ref: National Institute of Health NIH). Further examination of (R1's) Cedars Sinai Medical Records (dated 09/06/25 and 09/08/25) confirmed that (R1) sustained injuries from a fall, including abrasions, skin tears, and facial lacerations. Additionally, a review of Personnel Report LIC 500 (dated 09/11/25 & 09/15/25) revealed the facility had insufficient staffing with only one med-tech and caregiver on NOC shift schedule.

Based on the information gathered, there is sufficient evidence to support the allegation mentioned above.

Allegation #3: The facility does not have an auditory device or other staff alert feature to monitor exits.

The complaint details allege that the facility lacks an auditory device or staff alert system to monitor exits. Reports indicate that residents tend to wander around the unit, but the staff are often unaware when residents leave the building. There are no wander guard systems in place, and staff do not have any means to be alerted if a resident exits the facility. No additional information about this situation was provided.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 11-AS-20250909091421
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: 09/17/2025
NARRATIVE
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On September 12, 2025, between 10:18 AM and 12:15 PM, the Department interviewed staff members identified as Staff #1 through Staff #3. Three (3) out of the three (3) staff could not validate this claim. All staff confirmed that each floor has two fire exit doors, each equipped with a keyless alarm control keypad that leads to a stairwell. When the egress bar is activated, an auditory alert system will sound off an alarm. In the main lobby, a security panel displays information about the condition of each exit door, indicating whether it is open, bypassed, or tampered with. Additionally, the main lobby door is locked during nighttime hours. However, it is important to note that neither the rear receiving/delivery door nor the exterior gated rear door is equipped with any sensory alarms.

(S1) noted the incident when (R1) eloped from the facility during night shift of September 7, 2025, no exit door alarms sounded off and no indication on the security panel displays. (S1-S3) verified that the facility does not have surveillance cameras for added security.

The Department reviewed the (R1’s) Admissions Agreement (dated 08/29/25) including Delayed Egress Consent Form that Memory Care is a secured unit with Delayed Egress Alarms located at each exit door. Further review of the Facility Interior Floor Plan locations of all exit doors.

On September 12, 2025, the Department conducted an inspection of the Fire Exit Doors on the fourth floor where (R1) managed to exit both incidents September 7, 2025, and September 8, 2025, and observed both exit doors did not sound off the alarm when the egress bar was triggered. A facility pass code had to be keyed by a staff for the doors to work properly for the auditory alarm system to work. The Department further observed the kitchen double doors and receiving/delivery door had a delayed egress bars but had no alarm.

Based on the information gathered, there is sufficient evidence to support the allegation mentioned above.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegations are found to be SUBSTANTIATED.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 11-AS-20250909091421
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: 09/17/2025
NARRATIVE
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California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiencies were observed, and citation issued (ref. LIC 9099D).

*Immediate Civil Penalty issued*

An exit interview was conducted with Robin Culver, and copies of the reports were provided.

At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.”

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 11-AS-20250909091421
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/18/2025
Section Cited
CCR
87466
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87466 Observation of the Resident - The licensee shall ensure that residents are regularly observed for changes... and that appropriate assistance is provided... when such observation reveals unmet... When changes such as... deterioration of mental ability or a physical health condition... are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician.
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Licensee/Administrator shall have a written plan to ensure that in addition to the resident's needs and services plan a specific plan is drafted for each resident's change in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. The plan must be submitted by POC date 09/18/25 to ernand.dabuet@dss.ca.gov
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This requirement is not met as evidenced by:
Based on interviews, observation and record reviews, the Licensee was aware of (R1's) history of wandering behavior failed to ensure proper supervision and sustained serious injuries. This violation poses an immediate health and safety risk to residents in care.
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Type B
10/01/2025
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General (a) Facility personnel...shall be sufficient in numbers...to provide the services...to meet resident needs. Additional staff... employed...to perform...maintenance...and grounds.
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Licensee/Administrator have spoken and have agreed that management will hire an overnight staff in order to attend to residents' needs while in care. An updated LIC 500 will be sent to ernand.dabuet@dss.ca.gov by POC due date.
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This requirement is not met as evidenced by:
Based on LPAs observation and record reviews, the licensee did not ensure sufficient staff were present at the facility for NOC shift. This violation poses a potential health, safety, or personal rights risk to residents in care.
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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: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 11-AS-20250909091421
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/01/2025
Section Cited
CCR
87705(b)(d)
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87705 Care of Persons with Dementia (b)Licensees shall be responsible for the following...(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement...
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Licensee/Administrator have spoken and have agreed an auditory device will be install in all exit doors. Proof of invoice/receipt sent to ernand.dabuet@dss.ca.gov by POC due date.
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This requirement is not met as evidenced by:Based on LPA's observation, interviews, and record reviews. Liccensee failed to equip the kitchen and receiving/delivery exit doors with auditory devices. This violation poses a potential health, safety, or personal rights risk to residents in care.
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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: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 09/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7