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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320214
Report Date: 04/28/2026
Date Signed: 04/28/2026 11:10:20 AM

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
07/23/2025 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250723144509
FACILITY NAME:PACIFIC SUNRISE HOME 3FACILITY NUMBER:
198320214
ADMINISTRATOR:DANIEL, MONICA CENDANAFACILITY TYPE:
740
ADDRESS:28128 LOMO DRIVETELEPHONE:
(310) 938-6153
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:6; 6CENSUS: 6DATE:
04/28/2026
UNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Brenda Hernandez - AdministratorTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff did not prevent resident from developing a pressure injury
Staff did not notify resident's family of change in condition
INVESTIGATION FINDINGS:
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On 04/28/26 Licensing Program Analyst (LPA) Mario Leon arrived at the facility to provide updated findings on allegations listed above. LPA was met by Brenda Hernandez - Administrator (S1) and the purpose of the visit was explained. This report supersedes the previous report, provided on 03/27/26.
The investigation consisted of the following:
On 04/28/26 LPA delivered updated findings. On 03/27/26 LPA arrived to deliver these findings, related to the previous Administrator Monica Daniel. On 07/24/2025 LPA obtained copies of the staff (dated: 07/01/2025) and resident roster (dated: 07/04/2025) and requested documentation of three (3) residents (R1, R2 and R3), which include the following: Emergency identification form, Admission Agreement (dated: 01/2023 through 05/2025), Physician's report (dated: various) , physicians orders (dated: various), Medication Administration Records (dated: 06/2025 through 07/24/2025) and any communication between facility staff and the responsible party(ies). LPA was not able to obtain communication(s) between facility staff and the responsible party(ies), due to S1 needing technical assistance to produce LPA's request.
Report continues, please see LIC9099-C
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
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-20250723144509
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: PACIFIC SUNRISE HOME 3
FACILITY NUMBER: 198320214
VISIT DATE: 04/28/2026
NARRATIVE
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Regarding the allegation,"Staff did not prevent resident from developing a pressure injury" it is being alleged that staff did not rotate a resident (R1) while in care. Record reviews revealed the following: On 04/29/2025, R1 was noted with a Stage I pressure injury to their coccyx. Home Health advised the facility caregivers how to clean and apply the topical ointment to the area when R1’s adult brief is changed or when they (are) toileted. On 06/09/2025, R1 was noted with an additional pressure injury, Stage I, on their sacrum. On 06/16/2025, a physical therapy evaluation was conducted by the home health agency for R1. A wound to R1's right leg was discovered. On 06/19/2025, an additional Stage II pressure injury was discovered to R1's sacral area. On 06/26/2025, a third Stage II pressure injury was discovered on R1's sacrum. On 07/02/2025, home health noted the pressure injury had exacerbated to a Stage III. Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D.
Regarding the allegation, "Staff did not notify resident's family of change in condition" it is being alleged that the facility staff did not notify their responsible person of a change in condition. Record reviews revealed the following: From 07/04/25 through 07/16/25 there is mention of a wound from the responsible person, related to R1's current condition. Record reviews from 06/01/25 through 07/04/25 does not indicate wounds have been discovered by home health agency, despite the fact that new wounds have been indicated via home health record and that caregivers had been informed to notify a resident's (R1) of any change in condition on 06/02/25, 06/09/25, 06/16/25, 06/19/25 and 06/26/25. Based on record reviews and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited on the attached LIC 9099D.
There have been two (2) deficiencies cited during today's visit. An immediate civil penalty of $500.00 is being assessed. Please see LIC421IM.
At this time, an additional civil penalty determination is pending in reference to The Welfare and Institutions Code Section 15610.67 which defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.”
An exit interview was held and plans of corrections were developed with current Administrator, Brenda Hernandez, and a copy of this report and appeals rights have been provided.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 11-AS-20250723144509
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: PACIFIC SUNRISE HOME 3
FACILITY NUMBER: 198320214
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/06/2026
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1,...shall have all of the following personal rights: (4) To care, supervision...delivered by staff that are sufficient in numbers...competency to meet
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The licensee and LPA have agreed that facility staff will undergo in-staff training under additional personal rights, 87468.2. Licensee will forward in-staff training for all staff who are associated & working for this facility. Licensee will forward these tranings to LPA, via email, at mario.leon@dss.ca.gov
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their needs. This has not been met as evidenced by based on record reviews and interviews conducted the licensee failed to ensure that staff met R1's needs and seek timely medical attention for R1 when R1's condition worsened, this posed an immediate health and safety risk to residents in care.
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Type B
05/06/2026
Section Cited
CCR
87211(a)(1)(B)
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87211(a)(1)(B) Reporting Requirements
a) Each licensee shall furnish to the licensing agency such reports...:
(1) A written report shall be submitted to...the person responsible for the resident...(B) Any serious injury as determined by the attending physician and occurring while the resident is
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The licensee and LPA have agreed that facility staff will undergo in-staff training under reporting requirement 87211. Licensee will forward in-staff training for all staff who are associated & working for this facility. Licensee will forward these tranings to LPA, via email, at MARIO.LEON@DSS.CA.GOV
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under facility supervision. This has not been met as evidenced by record reviews and interviews conducted in licensee has not reported R1's pressure injuries to their responsible person, according to home health agencies' notifications on 06/02/25, 06/09/25, 06/16/25, 06/19/25 and 06/26/25 this posed a potential 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: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2026
LIC9099 (FAS) - (06/04)
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