<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320360
Report Date: 08/07/2026
Date Signed: 08/07/2026 04:30:34 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
01/26/2026 and conducted by Evaluator Troy Watson
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20260126152036
FACILITY NAME:OCEAN BREEZE CARE HOME IIIFACILITY NUMBER:
198320360
ADMINISTRATOR:MACELLVEN, GREGGFACILITY TYPE:
740
ADDRESS:1600 W 21STTELEPHONE:
(310) 721-9667
CITY:SAN PEDROSTATE: CAZIP CODE:
90732
CAPACITY:6CENSUS: 6DATE:
08/07/2026
UNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:House Manager - Jessica HallTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff restrain resident while in care.
Facility did not follow reporting requirements.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 08/07/2026, between 08:30 AM and 01:30 PM, Licensing Program Analyst (LPA) Troy Watson conducted an initial complaint visit to the facility listed above. LPA met with House Manager Jessica Hall and explained the purpose of the visit. LPA Watson was granted entry into the facility.

The investigation consisted of the following: On 01/30/2026, the department requested and obtained the following documentation: Register of Facility Residents, Staff Schedule, Medication Administration Record for R1, Staff Trainings, Physician’s Report for R1, Hospital Admission Record for R1, Residential Appraisal for R1, Hospice Care medication list, and Durable Medical Equipment document for R1. The department interviewed Staff #1–Staff #3 (S1–S3) and Residents #2–#6 (R2–R6). An attempt to interview Resident #1 (R1) was made; however, R1 was no longer living at the facility at the time of the complaint visit.

CONTINUED ON LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026
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 6
Control Number 11-AS-20260126152036
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: OCEAN BREEZE CARE HOME III
FACILITY NUMBER: 198320360
VISIT DATE: 08/07/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Staff restrain residents while in care.

It is alleged that the facility restrains a resident in care without authorization from family or a physician.

On 01/30/2026, the department interviewed Administrator Staff #1 (S1), Gregg MacEllven. During this interview, S1 was asked whether staff restrain residents while in care. S1 stated that staff do not restrain residents. S1 reported that R1 utilized a harness while seated in a wheelchair to help keep R1 upright due to paralysis on the right side of their body following a previous stroke. S1 also reported that the harness buckle was repaired while the resident was admitted to the hospital.

The department requested but did not obtain documentation showing a doctor’s order or approval for R1 to use a manual restraint as a postural support while in care. The department interviewed Staff #1–#(S1–S3) and Residents #2–#6 (R2–R6). Out of those interviewed, 3 out of 3 staff and 5 out of 6 residents denied the above allegation.Based on interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation, Staff restrain resident while in care, is found to be Substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are cited on the attached LIC9099D. Deficiencies were issued and plans of correction were discussed. Note: Citations not cleared by the due date will result in a $100 fine assessed for each citation until cleared. Civil penalties will continue to accrue until Proof of Correction (POC) is cleared.

Allegation: Facility did not follow reporting requirements.

It is alleged that the facility failed to follow required reporting procedures for incidents involving residents.

The department conducted an interview with Staff#1 (S1) and S1 was asked whether the facility follows the reporting requirements mandated by the California Department of Social Services. S1 stated that the facility does comply with reporting requirements.

CONTINUED ON LIC9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20260126152036
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: OCEAN BREEZE CARE HOME III
FACILITY NUMBER: 198320360
VISIT DATE: 08/07/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Regarding the fall incident on 01/19/2026, S1 reported that after noticing a lump on the resident, she immediately contacted the resident’s authorized representative and transported the resident to the hospital. S1 stated the authorized representative met her at the hospital approximately one hour later and assisted with verbal translation for the physician. S1 reported the resident was admitted to the hospital from 01/19/2026 to 01/23/2026. S1 also stated that the resident had experienced prior falls at home before being admitted to the facility and had previously been sent to Sea Crest Hospital due to those incidents. S1 reported discussing the incident with staff and reviewing supervision needs following the fall, noting that the resident “did not fall out of their wheelchair hard, but it was just a soft roll onto the carpet, resulting in no major injuries.”

The department interviewed Staff #1–#3 (S1–S3) and Residents #2–#6 (R2–R6). The department requested but did not obtain records showing that an Unusual Incident Report was submitted to Licensing due to R1 experiencing a fall at the facility and being admitted to the hospital as a result. As stated in Title 22, whenever an incident at the facility involves a resident’s health and safety and presents a potential risk, a report is required within 7 days of the occurrence.

The department interviewed Staff #1–#3 (S1–S3) and Residents #2–#6 (R2–R6). Out of those interviewed, 3 out of 3 staff and 5 out of 6 residents denied the above allegation.

Based on interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation, Facility did not follow reporting requirements, is found to be Substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are cited on the attached LIC 9099D. Deficiencies were issued and plans of correction were discussed.

Note: Citations not cleared by the due date will result in a $100 fine assessed for each citation until cleared. Civil penalties will continue to accrue until Proof of Correction (POC) is cleared.

An exit interview was conducted with Administrator Gregg MacElven, and a copy of this report was provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20260126152036
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: OCEAN BREEZE CARE HOME III
FACILITY NUMBER: 198320360
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/14/2026
Section Cited
CCR
87608(a)(3)
1
2
3
4
5
6
7
87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
The licensee agreed to conduct an in service training for all staff on section cited and residents personal rights. The licensee shall submit to the department a copy of the sign in sheet, and training materials, by the POC due date via email to troy.watson@dss.ca.gov
8
9
10
11
12
13
14
Based on interviews conducted and records reviewed, S1 acknowledged that a harness was placed on R1 since being admitted to the facility. The licensee did not have a physician’s order for Postural Supports. This poses a potential health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
08/14/2026
Section Cited
CCR
87211(a)(1)(B)
1
2
3
4
5
6
7
87211Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require…(1) A written report shall be submitted to…the person responsible for the resident within seven days of the occurrence of any of the events specified…below…(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.
1
2
3
4
5
6
7
The Licensee/Administrator agrees to:
1. Submit a complete written incident report containing all required elements for R1’s injury. 2. Conduct staff training on proper incident reporting procedures, including timelines and required documentation. 3. Provide a written statement to the Department confirming completion of corrective actions by the due date. Submit POC to: Troy.Watson@dss.ca.gov
8
9
10
11
12
13
14
This requirement is not met as evidenced by: Based on interviews, the licensee failed to submit a complete written report to (R1’s) responsible person (W1) regarding (R1’s) fall and hip fracture. This violation poses a potential health, safety, and personal rights risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
01/26/2026 and conducted by Evaluator Troy Watson
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20260126152036

FACILITY NAME:OCEAN BREEZE CARE HOME IIIFACILITY NUMBER:
198320360
ADMINISTRATOR:MACELLVEN, GREGGFACILITY TYPE:
740
ADDRESS:1600 W 21STTELEPHONE:
(310) 721-9667
CITY:SAN PEDROSTATE:CAZIP CODE:
90732
CAPACITY:6CENSUS: 6DATE:
08/07/2026
UNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:House Manager - Jessica HallTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility does not have enough staff.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 08/07/2026, between 08:30 AM and 01:30 PM, Licensing Program Analyst (LPA) Troy Watson conducted an initial complaint visit to the facility listed above. LPA met with House Manager Jessica Hall and explained the purpose of the visit. LPA Watson was granted entry into the facility.

The investigation consisted of the following:On 01/30/2026, the department requested and obtained the following documentation: Register of Facility Residents, Staff Schedule, Medication Administration Record for R1, Staff Trainings, Physician’s Report for R1, Hospital Admission Record for R1, Residential Appraisal for R1, Hospice Care medication list, and Durable Medical Equipment document for R1. The department interviewed Staff #1–Staff #3 (S1–S3) and Residents #2–#6 (R2–R6). An attempt to interview Resident #1 (R1) was made; however, R1 was no longer living at the facility at the time of the complaint visit.

CONTINUED ON LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20260126152036
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: OCEAN BREEZE CARE HOME III
FACILITY NUMBER: 198320360
VISIT DATE: 08/07/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation: Facility does not have enough staff.

It is alleged that the facility has not employed enough staff to adequately monitor and care for residents, resulting in a resident experiencing a fall at the facility.

On 01/30/2026, the department interviewed Administrator Greg MacEllven (S1). S1 was asked if the facility has enough staff, and S1 stated yes. Regarding the fall incident, S1 reported that the staff assigned to the resident was in the bathroom assisting another client with a bowel movement. S1 stated that staff heard the fall, responded immediately, assisted R1 back into their chair, assessed R1’s coherency, and notified the physical therapist, who then conducted an additional assessment.
The department interviewed Staff #1–#3 (S1–S3) and Residents #2–#6 (R2–R6). Out of those interviewed, 3 out of 3 staff and 5 out of 6 residents denied the above allegation.
The department obtained and reviewed the staff roster, which showed that the facility had enough trained staff available to adequately care for and monitor the residents in care.

The department interviewed Staff #1–#3 (S1–S3) and Residents #2–#6 (R2–R6). Out of those interviewed, 3 out of 3 staff and 5 out of 6 residents denied the above allegation.

Based on the information gathered, interviews conducted, and review of records, no evidence was found to support the allegation. Although the allegation may have happened or may be valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegation is Unsubstantiated.



An exit interview was conducted with House Manager Jessica Hall, and a copy of this report was provided.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Troy Watson
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2026
LIC9099 (FAS) - (06/04)
Page: 6 of 6