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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198203919
Report Date: 10/01/2025
Date Signed: 10/03/2025 05:52:55 PM

Substantiated


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 IIFACILITY NUMBER:
198203919
ADMINISTRATOR:MUQEET "MD" DAABHOYFACILITY TYPE:
740
ADDRESS:28024 CALZADA DR.TELEPHONE:
(310) 548-0898
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:6CENSUS: 6DATE:
10/01/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Edilberto BernardinoTIME COMPLETED:
05:00 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 is being revised to include additional information not previously documented. The updated LIC9099 report, dated 10/01/2025, will supersede and replace the original document. ***

On 05/01/2025, at 9:30 a.m., the Department conducted a subsequent visit to gather information regarding the above allegations and deliver findings. 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), Medication Administration Records (MARs) (05/02/2024-08/19/2024), See continued LIC9099-C page 2
Substantiated
Estimated Days of Completion:
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
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-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: 10/01/2025
NARRATIVE
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Continued LIC9099-C page 2

**This report has been amended to clarify findings. It does not supersede the report delivered on 10/01/2025. **
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). The Department also requested and received the following: Optum Health Service Medical Record for R1, Physicians Choice Home Health Medical records for R1, and Torrance Memorial Medical Center records for R1.

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.

Interviews were conducted with Staff Members #1-5 (S1-S5) as well as residents #2-4 (R2-R4) and witness 1 (W1). Resident #1 (R1) is no longer residing at the facility. The Department was able to interview the resident by telephone.

The investigation revealed the following:
Allegation: Resident sustained a pressure injury due to staff neglect. It is being alleged that resident 1 (R1) sustained a pressure injury on the right heel while at the facility.

On 05/01/2025, Resident #1’s (R1) records were requested and reviewed. R1 was admitted to the facility per the admissions agreement dated 05/01/2024. The Physician’s Report, signed on 05/01/2024, indicated no pressure injuries upon entry to the facility. Home Health records dated 04/23/2024 show that R1 was under the care of Optum Home Health. On 06/04/2024, notes from Physician’s Choice Home Health indicated that R1 had no pressure injuries at the time of that visit. On 06/26/2024, Optum Home Health documented notes show R1 had an unstageable pressure injury on R1’s right heel. R1 received wound treatments on 07/01/2024, 07/02/2024, and 07/03/2024, as documented in Physician’s Choice Home Health medical records. On 07/03/2024, R1 was admitted to Torrance Memorial Medical Center with the following diagnoses: Stage 2 pressure injury on the sacrum, suspected deep tissue injury on the left heel, and an unstageable right foot ulcer with suspected necrosis. See continued LIC9099-C page 3
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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: 10/01/2025
NARRATIVE
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Continued LIC9099-C page 3

The Department interviewed five staff members #1-5 (S1–S5) and one witness (W1) regarding concerns about Resident #1’s (R1) foot wound.

• S1 stated that R1 had a wound care nurse, but did not know the details of the wound care.

• S2 reported that R1 had their own nurse who treated a foot wound. S2 was unaware of the wound’s staging and alleged that R1 had the wound upon arrival at the facility.

• S3 stated that he observed a pressure injury on R1’s foot and informed R1. S3 also alleged that the wound was present when R1 arrived at the facility.

• S4 confirmed that R1 had a wound on the right foot upon arrival and was seen by a nurse, but did not know which home health agency provided care.

• S5 stated that R1 had their own nurse and was unaware of the wound’s staging.

• W1 reported that the Clinical Coordinator from Physician's Choice Home Health noted R1 developed a pressure injury on the right heel during their time at the facility, as documented on 06/26/2024.

All staff interviewed acknowledged that the resident had a pressure injury; however, none were aware of the wound’s staging or which home health agency was providing care. When a resident presents with a pressure injury, staff should receive training on appropriate wound site management and any necessary repositioning protocols. Based on the information gathered, it appears that such training may not have occurred in this instance.


See continued LIC9099-C page 4
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)
Page: 3 of 5
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: 10/01/2025
NARRATIVE
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Continued LIC9099-C page 4

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. All three residents (3 out of 3) denied the allegation and stated that their daily care needs were being met.

Regarding the allegation “Resident sustained a pressure injury due to staff neglect,” based on record reviews and interviews, the preponderance of evidence has been met; therefore, the allegation is Substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D, and an immediate $500 Civil Penalty is assessed.

At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.

An exit interview was conducted, appeal rights were discussed, and a copy of this report was provided to facility staff.
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)
Page: 4 of 5
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/22/2025
Section Cited
CCR
87466
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87466 Observation of the Resident

The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.
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The licensee agrees to ensure that staff receive training on Observation of the Resident and will submit documentation verifying that staff have been re-trained by the Plan of Correction (POC) due date of 10/22/2025.
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This requirement is not met as evidenced by:Resident #1 (R1) sustained a pressure injury on the right heel while residing at the facility.

This violation poses an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5