198203919-10-15-2025-11-AS-SCIS-DMJSS6-20251017140718

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198203919
Report Date: 05/01/2025
Date Signed: 10/15/2025 01:07:47 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/08/2024 and conducted by Evaluator Pamela Bunker

COMPLAINT CONTROL NUMBER: 11-AS-20241008101957

FACILITY NAME:	TLC GUEST HOME II		FACILITY NUMBER:	198203919
ADMINISTRATOR:	MUQEET "MD" DAABHOY		FACILITY TYPE:	740
ADDRESS:	28024 CALZADA DR.		TELEPHONE:	(310) 548-0898
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	6	CENSUS: 3	DATE:	05/01/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Leo Sumalpong		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident sustained a pressure injury due to staff neglect

INVESTIGATION FINDINGS:

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** The original LIC9099 report dated 05/01/2025 was revised to include additional information not previously documented. The updated LIC9099 report, dated 10/01/2025, will supersede and replace the original document shown below. ***

On 05/01/2025 at 9:30 a.m., the Department conducted an initial visit to gather information regarding the above allegations. The Department met with staff 1 (S1) Caregiver Leo Sumalpong and explained the purpose of today's visit. LPA was granted entry to the facility.

Investigation consisted of the following: On 05/01/2025, at 10:00 a.m., the department requested, reviewed and obtained copies of Resident Roster (Dated 03/18/2025), Personnel Report (Dated 03/15/2025), Admission Agreement (Dated 04/23/2024), Identification and Emergency Information (Dated 04/23/2024), Physician's Report (Dated 05/14/2024), Medical Assessment (Dated 03/05/2024),
See continued LIC9099-C page 2

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

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-20241008101957

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: TLC GUEST HOME II	FACILITY NUMBER: 198203919
	VISIT DATE: 05/01/2025

NARRATIVE

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Continued LIC9099-C page 2

Medication Administration Records (MARs) (05/02/2024-08/19/2024), Functional Capability Assessment (Dated 04/23/2024), Preplacement Appraisal Information (Dated 04/23/2024), Consent Forms (04/23/2024), 30-Day Notice from Resident (Dated 07/19/2024), and RN Sign In-Sheet (Dated 05/24/2024-07/10/2024). Interviews were conducted with Staff Members #1-2 (S1-S2) as well as residents #2-4 (R2-R4). Resident #1 (R1) is no longer residing at the facility. The Department was able to interview the resident by telephone.

On 10/24/2024 and 05/01/2025, the department toured the facility's buildings and grounds to observe and identify any signs of neglect, abuse, or other immediate health and safety threats. No signs of neglect or abuse were observed during today's visit.

The investigation revealed the following:
It was reported to the Department that resident sustained a pressure injury on the right heel while at this facility. The resident didn’t notice the injury until mid-June 2024. The CNA, who assists the resident and provides showers, stated it was difficult to see the area and assumed the resident was aware of the injury, saying, "I thought you knew." It was report that the resident visited a podiatrist (name not provided), who advised the resident to go to the emergency room. The resident went to the ER (hospital name not provided) on 07/03/2024, where they were given a medication ball containing antibiotics. the resident reportedly remained on antibiotics for six weeks and received wound care three times a week. It was also reported that due to presence of a “big black thing” covering the resident's heel, the doctors were unable to determine the stage of the wound, as they could not see beneath it. The condition reportedly did not improve, and the resident recently had to return to the ER. The name of the hospital was not disclosed, and no hospital records or discharge documents were provided. S1 and S2 stated the resident did not sustain a pressure injury due to staff neglect. 2 out of 2 stated the resident had his own private nurse and denied the allegation.

See continued LIC9099-C page 3

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20241008101957

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: TLC GUEST HOME II	FACILITY NUMBER: 198203919
	VISIT DATE: 05/01/2025

NARRATIVE

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Continued LIC9099-C page 3

Allegation: Resident sustained a pressure injury due to staff neglect
It was alleged resident sustained a pressure injury as a result of staff neglect. On 05/01/2025, between 10:00 a.m. and 12:45 p.m., the Department interviewed two staff members #1 and #2 (S1-S2), regarding the allegation. S2 stated the resident submitted a 30-day notice on 07/19/2024, indicating their intention to move out and actively looking for other accommodation. During that time, the facility did not observe any signs of discomfort or concerns related to the resident's care or needs. S2 also reported that the resident had a private nurse who visited three times a week to treat a wound on the resident's right heel. The documentation did not specify the stage of the wound. Both staff members interviewed (2 out of 2) confirmed that the facility does not admit or retain residents with pressure injuries above Stage 2, in accordance with Title 22 regulations. S2 stated they have been in business for over 30 years and strictly adhere to wound care regulations. S1 and S2 denied the allegation.

On 05/01/2025, between 2:00 p.m. and 2:30 p.m., on the same day, the Department conducted interviews with three residents #2-4 (R2–R4) regarding the allegation, and 3 out of 3 residents stated they did not observe any resident who appeared to require wound care. 3 out of 3 residents stated that the facility is fully staffed, they were happy living here, and confirmed they are receiving the necessary care and supervision. Residents (3 out of 3) denied the allegation and stated that their daily care needs were being met.

Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegations. 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 deemed unsubstantiated.

There were no deficiencies cited.

An exit interview was conducted.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025

LIC9099 (FAS) - (06/04)

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