198201933-5-30-2025-11-AS-RORN-DHQVSP-20250617164153

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201933
Report Date: 05/29/2025
Date Signed: 05/30/2025 07:47:51 AM

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
05/21/2025 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 11-AS-20250521124007

FACILITY NAME:	PALOS VERDES VILLA LLC		FACILITY NUMBER:	198201933
ADMINISTRATOR:	BIENSTOCK, SETH		FACILITY TYPE:	740
ADDRESS:	29661 S WESTERN AVE		TELEPHONE:	(310) 547-9941
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	116	CENSUS: 71	DATE:	05/29/2025
		UNANNOUNCED	TIME BEGAN:	08:53 AM
MET WITH:	Administrator Assistant Linda Cardenas		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident was hit by another resident while in care.

INVESTIGATION FINDINGS:

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On 05/29/25 at 9:00 am Licensing Program Analyst (LPA) Villegas conducted an initial complaint visit regarding the allegation(s) above. LPA met with (S1) Administrator Assistant Linda Cardenas as the purpose of today’s visit was explained.

The investigation consisted of the following: On 05/29/25 LPA Villegas obtained copies of the staff and resident roster, and copies of the following documents for Resident #1-2 (R1-R2) face sheet, admission agreement, physicians report, resident appraisal, medication list, and MAR for May 2025. On 05/29/25 from 10:00 am- 11:30 am LPA conducted Interviews with Resident #1-7 (R1-R7), from 1pm-1:15pm LPA conducted review of video footage from incident that occured on 5/19/25, and from 1:25pm-2pm interviews were conducted with staff #1-5 (S1-S5).

The investigation revealed the following:
Allegation: Resident was hit by another resident while in care.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025

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 11-AS-20250521124007

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: 05/29/2025

NARRATIVE

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It is being alleged that R2 yelled at and hit R1 on the arm.
On 05/29/25 from 10:00 am- 10:15am LPA conducted interview with R1 regarding the allegation above, R1 confirmed the allegation and reported being hit on the arm while being yelled at by R2. On 5/29/25 LPA attempted to conduct interview with R2 regarding the allegation above, R2 refused to be interviewed. On 5/29/25 from 10:20am- 11:30 am LPA conducted Interviews with R3-R7 regarding the allegation above, 5 of 7 residents interviewed denied the allegation above and reported feeling safe at Palos Verdes Villa LLC. On 5/29/25 from 1pm-1:15pm LPA conducted review of video footage from incident on 5/19/25, LPA observed R2 tapping on R1's left arm. On 5/29/25 from 1:25pm-2pm interviews were conducted with staff S1-S5, 5 of 5 staff denied the allegation above and reported that staff will intervene right away if the safety of any resident was in jeopardy. On 5/29/25 LPA confirmed and reviewed the incident report that was submitted to CCLD on 5/21/25 regarding the 5/19/25 incident between R1 and R2, per incident report, licensee and administrator conducted video review, interviews with staff and R1 and R2, and It was determined that R2 was tapping R1's arm, R1 was not observed asking/telling R2 to stop. On 5/29/25 LPA conducted a review of R1 and R2's physician reports, and resident appraisal, per documents neither resident has a history of aggression.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Exit interview conducted, and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025

LIC9099 (FAS) - (06/04)

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