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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198201933
Report Date: 03/20/2025
Date Signed: 03/20/2025 04:21:02 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
03/18/2025 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250318085530
FACILITY NAME:PALOS VERDES VILLA LLCFACILITY NUMBER:
198201933
ADMINISTRATOR:BIENSTOCK, SETHFACILITY TYPE:
740
ADDRESS:29661 S WESTERN AVETELEPHONE:
(310) 547-9941
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:116CENSUS: 84DATE:
03/20/2025
UNANNOUNCEDTIME BEGAN:
08:27 AM
MET WITH:Linda Cardenas, AdministratorTIME COMPLETED:
04:28 PM
ALLEGATION(S):
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9
Staff does not provide a variety of food.
INVESTIGATION FINDINGS:
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On 03/20/25 The Department of Social Services, Community Care Licensing Division (CCLD) conducted an initial complaint visit to gather information regarding the above allegation(s). CCLD met with staff one, Linda Cardenas, Administrator (S1) and the purpose of the visit was explained. CCLD was granted entry to the facility.
The investigation consisted of the following: On 03/20/25 CCLD requested Resident Roster (dated 03/20/2025), staff roster (dated 11/19/24), Admissions agreement, Needs and Services plan and Physician's Report for Resident two, four and five.(R2, R4-R5). CCLD was provided the facility's menus (dated 03/17/2025-03/23/2025), and the always available "alternative menu". CCLD also reviewed Dietician's Consultant Report (dated 02/19/25) and was provided six (6) certificates of training under Food Safety Training & Certification. CCLD interviewed nine (9) residents (R1-R9) and three (3) staff, and toured the first floor, the kitchen and the dining room.

Report continues, see LIC9099C.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
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 2
Control Number 11-AS-20250318085530
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: PALOS VERDES VILLA LLC
FACILITY NUMBER: 198201933
VISIT DATE: 03/20/2025
NARRATIVE
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The investigation revealed the following:

The investigation revealed the following:
Regarding the allegation, "Staff does not provide a variety of food.", it has been alleged that a resident was not served their request during their breakfast visit. On 03/20/2025, between 8:37am-1pm, CCLD interviewed residents #1-9 (R1-R9) and five (5) out of nine (9) residents interviewed do not agree with the allegation. On 03/20/2025, between 1pm-4pm, CClD interviewed Staff #1-3 (S1-S3) and three (3) out of three (3) staff interviewed denied the allegation has taken place. Record reviews revealed that there are two choices of food available for the meals of lunch and dinner, and that Milk or other beverages are provided during meal times. CCLD reviewed six (6) staff certificate of training under Food Safety Training & Certification, all which are valid and that the nearest certificate to expire is August 06, 2025. The "Dietician's Consultant Report" (dated 02/19/25) rated the facilities' kitchen as valid under the Dietician inspection and that the Dietician visits the facility monthly and that the facility was last visited on 03/19/25. CCLD also observed that the seating in the dining room is arranged and that each resident has a label of their name on their chair. Furthermore, each resident with a special diet has their special diet paperwork, under their seat's glass tabletop, to ensure staff are made aware of each resident's special diet.
Based on interviews, record reviews and CCLD's observation, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.
There has been zero deficiencies cited during today’s visit. An exit interview was held with staff one, Linda Cardenas (S1) Administrator, and a copy of this report has been provided.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Mario LeonTELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2