198204972-7-14-2026-11-AS-PMAA-DW6US5-20260720154945

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204972
Report Date: 07/14/2026
Date Signed: 07/14/2026 03:09:11 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
07/09/2026 and conducted by Evaluator Felisa Shirley

COMPLAINT CONTROL NUMBER: 11-AS-20260709135133

FACILITY NAME:	ROSECRANS VILLA RESIDENTIAL CARE		FACILITY NUMBER:	198204972
ADMINISTRATOR:	SANDRA LOPEZ		FACILITY TYPE:	740
ADDRESS:	14110 CORDARY AVENUE		TELEPHONE:	(310) 675-9163
CITY:	HAWTHORNE	STATE: CA	ZIP CODE:	90250
CAPACITY:	135	CENSUS: 115	DATE:	07/14/2026
		UNANNOUNCED	TIME BEGAN:	09:03 AM
MET WITH:	Sandra Lopez, Administrator		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff do not distribute resident's medications as prescribed
Staff do not safeguard resident's personal belongings

INVESTIGATION FINDINGS:

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On 7/14/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Administrator, Sandra Lopez and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility.

The investigation consisted of the following:
On 7/14/26 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Resident Face Sheet, Admission Agreement, Identification and Emergency Contact form, Physicians Report, Preplacement Appraisal, Appraisal Needs/Services Plan, Medication Administration Records, Residents Personal Property and Valuables, Unusual Incident Reports, Communications with Trust Representative. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff 5 (S1 – S5), and Resident 1 – Resident 5 (R1-R5).

Con'd on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026

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-20260709135133

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: ROSECRANS VILLA RESIDENTIAL CARE	FACILITY NUMBER: 198204972
	VISIT DATE: 07/14/2026

NARRATIVE

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LPA interviewed staff 1 – staff 5 (S1 – S5). Of those interviewed 5 out of 5 denied the allegation. LPA interviewed resident 1 – resident 5 (R1 – R5). Of those who interviewed 4 out of 5 denied the allegation. One resident confirmed the allegation.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not safeguard resident's personal belongings,” therefore, the allegation is unsubstantiated.

No deficiencies were cited for these allegations.

An exit interview was conducted and a copy of this report was provided to the Administrator, Sandra Lopez.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20260709135133

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: ROSECRANS VILLA RESIDENTIAL CARE	FACILITY NUMBER: 198204972
	VISIT DATE: 07/14/2026

NARRATIVE

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The investigation revealed the following:

Allegation: Staff do not distribute resident's medications as prescribed

It is being alleged that R1 is not receiving his prescribed medications for an antibiotic and a sleep aid. On 7/14/26, LPA Shirley observed an incident report dated 4/27/26. LPA Felisa Shirley reviewed R1’s Medication Administration Records, (MAR’s) April 2026 thru July 2026. LPA Shirley also observed medication prescription for Amoxicillin dated 4/23/26. Upon review of the incident report, on 4/23/26 R1 was sent to Gardena Memorial Emergency Department due to facial swelling. R1 was cleared and released to return to Rosecrans Villa the same day with a prescription for Amoxicillin. The resident was prescribed the antibiotic with 20 tablets to be taken twice a day for 10 days with zero refills. A review of the MAR for April the Med-Tech administered the medication on 4/25, 4/26 and 4/27. Per interview with the Administrator (S1), R1 was sent to a Skilled Nursing Facility on 4/28/26 and did not return to Rosecrans Villa until 5/28/26. The antibiotic was prescribed and administered until the supply was exhausted at the Skilled Nursing Facility. LPA Shirley also observed that the medication for Mirtazapine has a standing order to be administered daily at bedtime. This regimen has continued until R1’s hospitalization on 6/16/26. Following R1’s return on 6/23/26, the medication was resumed and remains active.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not distribute resident's medications as prescribed,” therefore, the allegation is unsubstantiated.

Allegation: Staff do not safeguard resident's personal belongings

It is being alleged that R1’s pants and shirts are missing. On 7/14/26, LPA Shirley observed and reviewed R1’s Resident Personal Property and Valuables form. LPA Shirley also received a copy of an emailed conversation between facility’s Administrator (S1) and R1’s Family Trust representative. The Resident Personal Property and Valuables form list 5 shirts and no pants as personal property when R1 arrived to this facility on 1/15/26. The email dated 2/4/26 between the Administrator and Trust Representative discusses R1 giving personal items away such as a jacket and a pair of shoes. The Administrator stated that she was not sure about other items that R1 may have given away.

Con'd on 9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 07/14/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026

LIC9099 (FAS) - (06/04)

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