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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320013
Report Date: 06/05/2025
Date Signed: 06/05/2025 04:40:45 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, 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
11/12/2024 and conducted by Evaluator Regina Cloyd
COMPLAINT CONTROL NUMBER: 11-AS-20241112123745
FACILITY NAME:SENIOR MANOR CARE IIIFACILITY NUMBER:
198320013
ADMINISTRATOR:STEPHEN GRADNEYFACILITY TYPE:
740
ADDRESS:2423 SANTA FE AVETELEPHONE:
(310) 212-0883
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY:6CENSUS: 5DATE:
06/05/2025
UNANNOUNCEDTIME BEGAN:
04:04 PM
MET WITH:Rodolfo "Nino" LozadaTIME COMPLETED:
04:55 PM
ALLEGATION(S):
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Staff did not seek timely medical care for resident.
INVESTIGATION FINDINGS:
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On 11/13/2024, CDSS (California Department of Social Services) Staff conducted an unannounced complaint investigation for the allegation listed above. On 12/11/24, CDSS Staff resumed the investigation. On 06/05/25, CDSS conducted a subsequent unannounced visit to deliver findings and met with Co-Administrator Rodolfo "Nino" Lozada.

The investigation consisted of the following:

On 11/13/2024, CDSS Staff conducted resident and staff interviews, toured the facility, and reviewed resident and staff records. On 12/11/24, CDSS Staff interviewed staff, resident #1 (R1) and witness #1 (W1), reviewed facility records, and visited Torrance Memorial Medical Center to request records. On 02/13/25, CDSS Staff interviewed Witness #2 (W2) over the phone. On 02/27/25, CDSS Staff reviewed EMS report from Torrance City Clerk’s Office. On 05/23/2025, CDSS Staff obtained R1’s medical record from Torrance Memorial Medical Center. Continue to LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
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 3
Control Number 11-AS-20241112123745
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: SENIOR MANOR CARE III
FACILITY NUMBER: 198320013
VISIT DATE: 06/05/2025
NARRATIVE
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Regarding the allegation "Facility staff did not seek timely medical care for resident,” It is being alleged that staff did not immediately call 911 after verifying that a resident was unresponsive. Records review revealed the following: Facility Daily Time Sheet revealed staff S2 and S3 were working at facility on 11/11/2024. The Emergency Medical Services report indicates that on 11/11/2024 at around 10:52am the paramedics arrived at the facility, observed that R1’s pulse was low and transported R1 to Torrance Memorial Hospital. Interviews indicate the following: S2 indicated that on 11/11/2024 around 9:00am, S2 observed R1 to be unresponsive. S2 and W2 attempted to wake R1 and W2 told S2 not to call 911 which S2 complied. S2 indicated that W1 arrived at 10:30am, attempted to wake R1, and then W1 called 911. S2 acknowledged S2 should have called 911 regardless of W2. W1 indicated finding out that R1 has been unresponsive for 90 minutes and W1 decided to call 911. On 02/13/25, CDSS Staff interview with W2 indicated S2 wanted to call 911 but W2 told S2 not to call.

Regarding the allegation “Facility staff did not seek timely medical care for resident,” based on record reviews and interviews, the preponderance of evidence has been met therefore the allegation is Substantiated.

Deficiencies were issued.



An exit interview was conducted and plans of correction developed. A copy of this report, and appeals rights was reviewed and left with the Co-Administrator Rodolfo "Nino" Lozada.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20241112123745
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: SENIOR MANOR CARE III
FACILITY NUMBER: 198320013
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/06/2025
Section Cited
CCR
87465(g)
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Incidental Medical and Dental Care. (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).
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The Licensee will provide a plan of correction and email it to regina.cloyd@dss.ca.gov by the POC due date.
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This requirement was not met by evidence by:

Based on record review and interviews, Staff #2 (S2) did not immediately call 911 when S2 saw that Resident #1 was unresponsive. This posed an immediate risk to resident's health while 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: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3