197607718-9-3-2026-11-AS-PMAA-DYDMJW-20260929093950

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607718
Report Date: 09/03/2026
Date Signed: 09/03/2026 01:59:14 PM

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
08/25/2026 and conducted by Evaluator Troy Watson

COMPLAINT CONTROL NUMBER: 11-AS-20260825081642

FACILITY NAME:	CENTINELA ASSISTED LIVING CENTRE		FACILITY NUMBER:	197607718
ADMINISTRATOR:	GWENDOLYN CRAIG		FACILITY TYPE:	740
ADDRESS:	1000 S FLOWER ST		TELEPHONE:	(310) 674-3216
CITY:	INGLEWOOD	STATE: CA	ZIP CODE:	90301
CAPACITY:	96	CENSUS: 52	DATE:	09/03/2026
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Social Services Coordinator - Elizabeth Hernandez		TIME COMPLETED:	01:58 PM

ALLEGATION(S):

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Staff do not ensure residents care plan is followed.
Staff do not ensure resident is provided a comfortable environment.

INVESTIGATION FINDINGS:

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On 09/03/26 Licensing Program Analyst (LPA) Troy Watson conducted an initial complaint visit to the facility listed above. LPA Watson was greeted by the Social Services Director Elizabeth Hernandez, and the purpose of the visit was explained. LPA Watson was granted entry into the facility.

Investigation consisted of the following:

On 09/02/2026 the department requested, and obtained the following documentation: Resident Roster, Staff Roster, Admission Agreement for R1, R2 dated 08/04/26, 08/06/26, Medication Review Report for R1, R3 dated 09/02/26, Physicians Report for R1, R3 dated 08/03/26, 10/03/23, Technical Support Program for R3 dated 10/10/23, Care Plan for R1, R3 dated 08/03/26, 10/03/23, Telephone Memo dated 07/07/26.The department conducted interviews with Staff#1-#6 (S1-S6) and Residents#1-#5 (R1-R5).

CONTINUED ON LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2026

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

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20260825081642

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: CENTINELA ASSISTED LIVING CENTRE	FACILITY NUMBER: 197607718
	VISIT DATE: 09/03/2026

NARRATIVE

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Investigation revealed the following:

Allegation: Staff do not ensure residents’ care plan is followed.

It is alleged that staff are not ensuring R1 receives physical therapy to regain mobility after a hip fracture but keeps R1 in a wheelchair instead.

On 09/02/2026 the department conducted an interview with the Administrator Yisroel Rosman, Staff#1 (S1). During an interview with S1 the department asked if staff ensured residents’ care plans are followed. S1 said yes, we review their care plans and monitor their care plans annually and make changes immediately based on their change of conditions. During the interview the department asked S1 what physical therapy services are ordered or recommended for Residents and what is the facility’s responsibility in carrying out those orders? S1 said we don’t offer or provide physical therapy here at the facility, but the medtech will evaluate them and if needed we will call their primary care physician or home health and they will schedule therapy for the residents if needed.

On 09/02/2026 the department conducted interviews with Staff#1 -#6 (S1-S6) and Residents #1 - #5 (R1-R5). Out of those interviewed 6 out of 6 staff and 4 out of 5 residents denied the above allegation.

The department reviewed a copy of R1’s Care Plan and it showed on page 12 under the heading 15 Mobility Needs that R1 is independent and uses a manual wheelchair and walker for mobility. Further review of the Care Plan did not show or recommend any physical therapy to be given to R1 so that R1 could walk again. On 09/04/26 the department conducted an interview with R1 and R1 was asked, have you been informed that physical therapy is part of your care plan in relation to your hip injury or to help you walk again and, R1 said no. The department also asked R1 during the interview, since arriving at this facility, have you received any physical therapy sessions, and R1 said no.

Based on the information gathered, interviews conducted, and an analysis of records reviewed, the department found no evidence to support the allegation mentioned above. 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.

CONTINUED ON LIC9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2026

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20260825081642

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: CENTINELA ASSISTED LIVING CENTRE	FACILITY NUMBER: 197607718
	VISIT DATE: 09/03/2026

NARRATIVE

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Allegation: Staff do not ensure R1 is provided with a comfortable environment.

It is alleged that staff wake up R1 unexpectedly throughout the night, resulting in insufficient sleep.

On 09/02/2026 the department conducted an interview with the Administrator Yisroel Rosman, Staff#1 (S1). During the interview S1 was asked do staff ensure residents are provided with a comfortable environment and S1 said yes, we try to the best of our ability to accommodate our residents’ needs and make them feel comfortable. S1 also said that the facility purchased a new van to transport residents safely and make sure they make their appointments on time. S1 also said the facility makes sure the residents’ rooms are cleaned, and that residents are presentable and prepared to see their families as well. The department also asked S1 under what circumstances are staff entering the resident’s room at night, and is there a reason any resident would be woken multiple times? S1 said there is no reason for anyone to enter a resident’s room unless it’s to give them medication or to wake a resident for dinner or an emergency. We have scheduled room checks to make sure they are changed and to make sure everyone is physically O.K.

On 09/02/2026 the department conducted interviews with Staff#1 -#6 (S1-S6) and Residents #1 - #5 (R1-R5). Out of those interviewed 6 out of 6 staff and 4 out of 5 residents denied the above allegation.

On 09/03/2026 the department conducted an interview with R1 and R1 was asked are staff waking you up during the night, and if so, how often. R1 said I know they knock and come in to check on us to see whether we are still breathing or not, but they don’t knock so loud anymore they stopped about a week ago. The department also asked R1, do you feel you are getting enough rest at night? R1 said yes.

Based on the information gathered, interviews conducted, and an analysis of records reviewed, the department found no evidence to support the allegation mentioned above. 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.

An Exit interview was conducted with the Assistant Administrator Mosha Sacks and a copy of this report was given.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2026

LIC9099 (FAS) - (06/04)

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