198204972-5-12-2026-11-AS-PMAA-DXKSLR-20260903135843

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204972
Report Date: 05/12/2026
Date Signed: 05/12/2026 04:43:39 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
05/07/2026 and conducted by Evaluator Felisa Shirley

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20260507160358

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: 100	DATE:	05/12/2026
		UNANNOUNCED	TIME BEGAN:	08:49 AM
MET WITH:	Sandra Lopez, Administrator		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

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Staff mismanages resident's medication
Staff do not prevent resident from menacing other resident

INVESTIGATION FINDINGS:

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On 5/12/26, 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 5/12/26 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Certification for all Medication Technicians, Medication Administration Records (MAR’s), Assessment 4/9/26, Client/Resident Personal Property and Valuables Form LIC 621, Appraisal/Needs and Services Plan, Medical Assessment for Residential Care Facilities for the Elderly, LIC602A, Identification and Emergency Information, Admission Agreement, 8/19/25. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff- 5(S1 – S5), and Resident -1 – Resident – 10 (R1-R10).

Con'd on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

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-20260507160358

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: 05/12/2026

NARRATIVE

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The investigation revealed the following:

Allegation: Staff mismanages resident's medication

It is being reported that staff refuses to give R1 there medication at the right time. On 5/12/26, LPA Felisa Shirley reviewed an assessment by R1’s Primary Care Physician dated 4/9/26. This assessment states that R1 does not have the capacity to understand and make decisions. During review of the 4 Medication Technicians (Med Tech’s) training records on 5/12/26, LPA Shirley noted that all 4 Med Techs have the knowledge required to safely assist residents with prescribed medications. On 5/12/26, LPA Shirley reviewed 5 resident’s, including R1’s Medication Administration Records, (MAR’s) for the months of April and May. No discrepancies were identified during the review. Per interview with 2 Med Techs, S5 and S6 on 5/12/26, stated that R1 frequently checks in at the medication room, arriving every 15 minutes to inquire about her medication. Per interview with S6 on 5/12/26, the resident shows signs of forgetfulness. Per interview with S6 on 5/12/26, she stated, if the Med Tech are unavailable, R1 will inquire about the Med Techs whereabouts from non-med tech staff. On 5/12/26, LPA Shirley observed R1 in the hallway in the facility and had to identify myself to the resident and had to explain why I was here. During a tour of this facility at 12:04pm on 5/12/26 with S1, we passed by R1’s room and the resident asked S1 if it was time for her medication. On 5/12/26 at 1:15pm, LPA Shirley went to R1’s room to ask her a question and R1 inquired if it was time to take her medication.

LPA interviewed staff 1 – staff 6 (S1 – S6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 1 – resident 10 (R1 – R10). Of those who interviewed 8 out of 10 denied the allegation. One resident confirmed the allegation and 1 resident was not sure.

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

Allegation: Staff do not prevent resident from menacing other resident

It is being reported that R1’s roommate has made sexually explicit comments to her while standing over her bed at night, which makes R1 very uncomfortable and anxious. During review of R1’s facility file on 5/12/26, LPA Felisa Shirley did not observe any reports of R1’s roommate that mentioned harassment of R1. During interviews on 5/12/26, the Administrator, (S1), stated that she has not received any complaints of harassment from R1

con'd on 9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20260507160358

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: 05/12/2026

NARRATIVE

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regarding her assigned roommate. Per interview with the Administrator on 5/12/26, she did not receive a request for R1 to change rooms as S1 had no knowledge of R1 claims that her roommate was harassing her. Per interview with the Administrator, there are no reports of roommates harassing there roommates within the facility.

LPA interviewed staff 1 – staff 6(S-1 – S-). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 1 – resident 10 (R1 – R10). Of those who interviewed 6 out of 10 denied the allegation. Three resident confirmed the allegation and one resident was not sure.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not prevent resident from menacing other resident,” 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: 05/12/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2026

LIC9099 (FAS) - (06/04)

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