197610201-9-24-2025-31-AS-TAGD-DMJT9F-20251017143153

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610201
Report Date: 09/24/2025
Date Signed: 09/24/2025 03:52:17 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/16/2024 and conducted by Evaluator Melissa Spaeth

COMPLAINT CONTROL NUMBER: 31-AS-20240216171149

FACILITY NAME:	4 ALL SENIORS CARE HOME		FACILITY NUMBER:	197610201
ADMINISTRATOR:	SAMANIEGO, JOHN ROEL		FACILITY TYPE:	740
ADDRESS:	744 VANDALWAY		TELEPHONE:	(661) 400-4948
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	6	CENSUS: 4	DATE:	09/24/2025
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Marita Samaniego		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff neglect led to resident developing pressure injuries.
Staff did not address resident's change in condition while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced subsequent complaint investigation for the allegation(s) listed above. LPA was greeted by the Administrator Marita Samaniego. LPA explained that the reason for the visit was to deliver the findings for this complaint. LPA toured the facility from 2:20 until 2:30 pm.

On 02/21/2024 Licensing Program Analyst (LPA) Melissa Spaeth and Licensing Program Manager (LPM) Troy Agard initiated a complaint investigation for the allegation(s) listed above. LPA Spaeth explained the purpose of the visit was to investigate a complaint. LPM requested copies of the following documents: (1) staff roster; (2) resident roster; (3) copies of the residents' files; and (4) staff work schedule from 2/01/2023 until 2/21/2024. The Administrator provided the documentation. LPA conducted a physical plant tour from 11:00 am until 11:15 am.

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025

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 31-AS-20240216171149

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: 4 ALL SENIORS CARE HOME	FACILITY NUMBER: 197610201
	VISIT DATE: 09/24/2025

NARRATIVE

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On 2/16/2024, a complaint was received by the Woodland Hills Adult & Senior Care Regional Office. The complaint was referred to Community Care Licensing Division’s Investigation Branch (IB) on 4/02/2025 for a full investigation and was accepted on 4/02/2025.

An investigation was conducted by IB Investigator, Jose Santana. During the course of the investigation, Investigator Santana interviewed four out of four residents (R1-R4), the Administrator, and two out of seven staff members (S1-S2). IB Investigator Santana also received copies of R1’s medical records and hospice records. LPA Spaeth conducted additional interviews with staff (S1-S3) on 6/27/2025 at 4:00 pm.

Regarding the allegation: Staff neglect led to a resident developing pressure injuries - It is being alleged R1’s pressure injuries were due to facility staff not cleaning R1 and not keeping R1 dry. R1 was diagnosed with cachexia, had leg contractures, experienced pain with movement, and was not eating. R1 entered hospice on 8/21/2023. Between 8/28/2023 to 10/04/2023, R1 developed two (2) stage two (2) pressure injuries located on their sacrum and right hip, one (1) pressure injury on their buttocks and one (1) pressure injury on their left hip. Between 10/02/2023 to 1/22/2024, R1’s pressure injuries progressed to stage 4. Between 2/12/2024 to 2/26/2024, R1 developed two new wounds on their lateral right buttock.

On 10/19/2023, the hospice nurse documented that R1 had a measurable decline within the preceding two weeks. The nurse also noted that R1 was difficult to reposition due to R1 sleeping up to 20 hours per day and also due to the discomfort experienced by R1 when repositioned. R1’s wounds were still present despite the two times a week wound care, repositioning, protein intake, and the use of a low air loss mattress. Three (3) out of seven (7) staff members unanimously stated they check residents every two to three hours to determine if residents require a diaper change and to ensure residents are dry. R1 confirmed they are checked every two to three hours for a diaper change

Continued on 9099-C

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20240216171149

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: 4 ALL SENIORS CARE HOME	FACILITY NUMBER: 197610201
	VISIT DATE: 09/24/2025

NARRATIVE

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Regarding the allegation: Staff did not address resident's change in condition while in care – It is being alleged staff did not address R1’s change in condition and staff left R1 in a urine-soaked bed. S1-S3 confirmed they never leave a resident in a urine-soaked bed and have never been advised by any staff member or an outside source that this has occurred. S1-S3 confirmed they checked R1 every hour when they observed R1’s change in condition. S1-S3 also stated they never left R1 in a wet diaper for a long period of time and continued to reposition R1 every two hours. S4 was unavailable for an interview.

Based upon the interview of the Administrator, staff members, and residents, the allegations are unsubstantiated.

Exit interview conducted and a copy of the report was given.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2025

LIC9099 (FAS) - (06/04)

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