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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607906
Report Date: 09/25/2026
Date Signed: 09/25/2026 12:18:55 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
09/11/2026 and conducted by Evaluator Perry Scott
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20260911143359
FACILITY NAME:TWIN HOMECARE - AFACILITY NUMBER:
197607906
ADMINISTRATOR:NAPOLEON GARCIAFACILITY TYPE:
740
ADDRESS:2104 W. 242ND STREETTELEPHONE:
(424) 263-4779
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY:6; 6CENSUS: 6DATE:
09/25/2026
UNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Liza BuencilloTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Questionable Death
Staff do not provide adequate food service
Licensee does not ensure staff are properly trained
Staff do not ensure the facility is free of insects
Staff do not ensure the facility is in good repair
Staff did not ensure resident was adequately fed resulting in resident losing
weight
INVESTIGATION FINDINGS:
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On 9/14/26, at 9:30am, the department conducted an initial complaint visit to the facility and was greeted by Liza Buencillo, Caregiver. The department explained the purpose of this visit was to gather facility files, tour the facility, and do a health and safety check on the residents.

The investigation consisted of the following: The department toured the facility, inspected the kitchen, and observed that there is enough perishable and non-perishable food available for all residents in care. All food items were stored properly. The department did not observe any spoiled food. The department observed that the facility has ongoing construction to fix the fence on the property and it is almost completed. On 09/25/2026, the department conducted a subsequent visit and interviewed staff and residents. The department requested and received the following documents from the facility: Resident Roster, Personnel Report, Medical Assessment (Dated: 07/31/2025), Identification and Emergency Information (Dated: 08/17/2024), Death Report (Dated:08/17/2014), Resident Appraisal (Dated:11/15/2024), Appraisal And Needs Service Plan (Dated:09/17/2025), Personnel Records, Hospice Care Plan, Hospice Medication Administration Record, and Staff Training Certifications.

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

DATE: 09/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2026
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-20260911143359
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: TWIN HOMECARE - A
FACILITY NUMBER: 197607906
VISIT DATE: 09/25/2026
NARRATIVE
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The investigation revealed the following: Allegation #1- Questionable Death.

The details of the complaint alleged that because of a change in management and new caregivers the resident had a sudden decline in health condition due to the new caregivers. On 9/25/2026, from 9:00am-12:00pm, the department interviewed staff (S1-S4) and residents (R1-R2) regarding the allegation. The department attempted to interview the other four residents but could not be due to cognitive issues. 3 of 4 staff denied the allegation of a Questionable Death. The majority of the staff stated that the former resident died of cardiac arrest and was on hospice. S1-S3 stated that the resident was on hospice and had underlying health issues and denied any type of neglect. While the other staff member was newly hired and did not know the resident.

The department interviewed residents (R1-R2) about the allegation and 2 of 2 residents that were interviewed could not corroborate the allegation. The department attempted to interview the other four residents but could not be due to cognitive issues.

The department reviewed the Death Report (Dated:08/17/2014), Appraisal And Needs Service Plan (Dated:09/17/2025), Hospice Care Plan, Hospice Medication Administration Record, and Medical Assessment (Dated: 07/31/2025) and observed that the resident died of a cardiac arrest and had other underlying health conditions. The department did not find any evidence of neglect of the resident.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Questionable Death. 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 #2-Staff do not provide adequate food service.

The details of the complaint alleged that staff were not providing enough food for the resident and were told by the owner to freeze all expired food and use it for the resident. On 9/25/2026, from 9:00am-12:00pm, the department interviewed staff (S1-S4) and residents (R1-R2) regarding the allegation. The department attempted to interview the other four residents but could not be due to cognitive issues. 4 of 4 staff denied the allegation Staff do not provide adequate food service. All staff stated that the residents are given three meals a day plus snacks and are provided adequate food service.

The department interviewed residents (R1-R2) about the allegation and 2 of 2 residents that were interviewed could not corroborate the allegation. Residents stated that they are provided enough food to eat and have no complaints. The department attempted to interview the other four residents but could not be due to cognitive issues.

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

DATE: 09/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20260911143359
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: TWIN HOMECARE - A
FACILITY NUMBER: 197607906
VISIT DATE: 09/25/2026
NARRATIVE
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The department toured the facility, inspected the kitchen, and observed that there is enough perishable and non-perishable food available for all residents in care. The department also observed meal preparation for the residents and did not find that food service was inadequate.

Based on interviews and observations, there is insufficient evidence to support the allegation that Staff do not provide adequate food service. 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-Licensee does not ensure staff are properly trained.

The details of the complaint allege that staff are not properly trained to care for the residents. On 9/25/2026, from 9:00am-12:00pm, the department interviewed staff (S1-S4) and residents (R1-R2) regarding the allegation. The department attempted to interview the other four residents but could not be due to cognitive issues. 4 of 4 staff denied the allegation Licensee does not ensure staff are properly trained. All staff stated that they have remained in compliance with all training required for the facility.

The department interviewed residents (R1-R2) about the allegation and 2 of 2 residents that were interviewed could not corroborate the allegation. Residents stated that they believed all staff was trained to care for their health needs and had no complaints about their care. The department attempted to interview the other four residents but could not be due to cognitive issues.

The department reviewed the Personnel Records and Staff Training Certifications and observed that the staff were up to date on all training required.

Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Licensee does not ensure staff are properly trained. 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 ensure the facility is free of insects.

The details of the complaint allege that the facility does not keep the facility free from insects. On 9/25/2026, from 9:00am-12:00pm, the department interviewed staff (S1-S4) and residents (R1-R2) regarding the allegation. The department attempted to interview the other four residents but could not be due to cognitive issues. 4 of 4 staff denied the allegation Staff do not ensure the facility is free of insects. All staff stated that the facility does not have an insect or pest issue.

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

DATE: 09/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20260911143359
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: TWIN HOMECARE - A
FACILITY NUMBER: 197607906
VISIT DATE: 09/25/2026
NARRATIVE
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The department interviewed residents (R1-R2) about the allegation and 2 of 2 residents that were interviewed could not corroborate the allegation. Residents stated they have not seen any insects or pests and that the staff keeps the facility well maintained. The department attempted to interview the other four residents but could not be due to cognitive issues.

The department toured the facility and observed the facility to be clean, well maintained, and did not observe any insects flying around the facility nor pests of any kind.

Based on interviews and observations, there is insufficient evidence to support the allegation that Staff do not ensure the facility is free of insects. 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 #5-Staff do not ensure the facility is in good repair.

The details of the complaint allege that the facility is not in good repair and that the fence needs to be fixed. On 9/25/2026, from 9:00am-12:00pm, the department interviewed staff (S1-S4) and residents (R1-R2) regarding the allegation. The department attempted to interview the other four residents but could not be due to cognitive issues. 4 of 4 staff denied the allegation Staff do not ensure the facility is in good repair. All staff stated that they believed the facility was in good repair. Staff also stated that the fence has been repaired for some time.

The department interviewed residents (R1-R2) about the allegation and 2 of 2 residents that were interviewed could not corroborate the allegation. Residents stated the facility is clean and well maintained by the staff. The department attempted to interview the other four residents but could not be due to cognitive issues.

The department toured the interior and exterior of the facility and observed the facility to be clean, not in disrepair, and any issues with the fence has been resolved. The facility has installed brand new fencing around the facility.

Based on interviews and observations, there is insufficient evidence to support the allegation that Staff do not ensure the facility is in good repair. 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 did not ensure resident was adequately fed resulting in resident losing weight.

The details of the complaint allege that the facility staff did not ensure resident was adequately fed, resulting in them losing weight. On 9/25/2026, from 9:00am-12:00pm, the department interviewed staff (S1-S4) and residents (R1-R2) regarding the allegation. The department attempted to interview the other four residents but could not be due to cognitive issues.

Report Continued On LIC9099-C

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

DATE: 09/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20260911143359
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: TWIN HOMECARE - A
FACILITY NUMBER: 197607906
VISIT DATE: 09/25/2026
NARRATIVE
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4 of 4 staff denied the allegation Staff did not ensure resident was adequately fed resulting in resident losing weight. All staff stated that the residents receive three meals per day plus snacks. They also stated that some residents do not have the ability to eat a lot of food and that their appetite is limited. They also stated that they had a former resident who had passed away, that did not have a very good appetite and would eat about 30% of their breakfast and 20% of their other meals. They stated that the resident was on hospice and could not eat a lot. They deny that they may have neglected the resident in any way.

The department interviewed residents (R1-R2) about the allegation and 2 of 2 residents that were interviewed could not corroborate the allegation. Residents stated that they do get enough food to eat and have not lost any weight due to staff not feeding them. The department attempted to interview the other four residents but could not be due to cognitive issues.

The department toured the facility and did not observe any resident that seemed to be malnourished or neglected.

Based on interviews and observations, there is insufficient evidence to support the allegation that Staff did not ensure resident was adequately fed resulting in resident losing weight. 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 Liza Buencillo, Caregiver, and a hard copy of this Complaint Investigation Report was provided.

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

DATE: 09/25/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/25/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5