198320397-6-5-2026-11-AS-EMAZ-DV5VR3-20260617163916

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320397
Report Date: 06/05/2026
Date Signed: 06/05/2026 06:17:50 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
06/01/2026 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20260601151344

FACILITY NAME:	DIVINE LIFE GUEST HOME		FACILITY NUMBER:	198320397
ADMINISTRATOR:	ROSALDO, RODRIGO		FACILITY TYPE:	740
ADDRESS:	1711 W. 243RD ST.		TELEPHONE:	(310) 310-1851
CITY:	LOMITA	STATE: CA	ZIP CODE:	90717
CAPACITY:	6	CENSUS: 5	DATE:	06/05/2026
		UNANNOUNCED	TIME BEGAN:	08:08 AM
MET WITH:	Rodrigo Rosaldo		TIME COMPLETED:	04:58 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff holds resident down resulting in injuries.
Staff do not change residents timely.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On June 5, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Ernand Dabuet, conducted an initial unannounced complaint visit. Rodrigo Rosaldo Administrator, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegations mentioned above.

The investigation included interviews, inspection of the facility, and a collection of documents. The Department reviewed (R1’s) Physician’s Report LIC (dated 05/29/25), Identification and Emergency Information LIC 601 (dated 05/29/25) Medication Profile (dated 12/01/25), Appraisal/Needs and Services Plan LIC 625 (dated 05/29/25) Admissions Agreement (dated 0729/25), Unusual Incident Report LIC 624 (dated 05/30/26) Facility Progress Notes (dated 05/02/26 – 05/30/26) and Torrance Memorial Medical Assessment (dated 05/31/26). Interviews conducted with Resident#1 through #5 (R1-R5) and Staff #1 through Staff #3 (S1-S3).

(Evaluation Report continues on LIC 9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2026

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 4

Control Number 11-AS-20260601151344

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: DIVINE LIFE GUEST HOME	FACILITY NUMBER: 198320397
	VISIT DATE: 06/05/2026

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

INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: Staff holds resident down resulting in injuries.

It is alleged that the staff physically restrained Resident #1 (R1), resulting in injuries. Reports indicate that the facility staff used physical restraint on (R1), leading to cuts on (R1's) arms. No additional information about the incident has been provided.

On June 5, 2026, between 09:30 AM and 01:25 PM, the Department interviewed staff members identified as Staff #1 through Staff #3. Three (3) out of the three (3) staff members could not support this claim. Resident #1 (R1) was feeling unwell, impacting (R1’s) mood and mental clarity associated with the behaviors from the infecton. Staff (S1) contacted (R1's) responsible party, and (R1) was admitted to Torrance Memorial Hospital on May 30, 2026, for medical evaluation. The Torrance Memorial Medical Assessment (dated 05/31/26), indicated that (R1) is being treated for a urinary tract infection. (S1-S3) firmly denied any use of restraining (R1) in their caregiving or supervision. They disputed (R1) ever sustaining injuries resulting from manual or physical restraint.

On June 5, 2026, between 9:45 AM and 10:25 AM, the Department interviewed resident members identified as Resident #2 through Resident #5 (R1-R5). Five (5) out of the (5) five residents cannot support this claim. All reported feeling well-treated by the staff and stated that they have not undergone any physical restraint or sustained any injuries while in care.

On June 5, 2026, between 10:40 AM and 11:23 AM, the Department interviewed resident member identified as Resident #1 (R1) at Torrance Memorial Hospital. (R1) confirmed was admitted for medical care due to Urinary Tract Infection. Resident (R1) reported that a staff member at the facility would hold (R1) in a way that caused cuts on (R1’s) right wrist and arm. (R1) could not remember when the incident occurred or name the staff member involved, but (R1) indicated that this behavior is ongoing. However, (R1) clarified that it was not physical abuse and did not wish to provide further details. Overall, (R1) stated that (R1) have been treated well by the facility's staff and feel safe living there.

During the interview with (R1), the Department observed that there were no fresh cuts, scrapes, or bruises on (R1’s) arms.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20260601151344

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: DIVINE LIFE GUEST HOME	FACILITY NUMBER: 198320397
	VISIT DATE: 06/05/2026

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

On June 5, 2026, between 11:32 AM and 12:32 PM, the Department interviewed witness members identified as Witness #1 and Witness #2 (W1-W2). Two (2) out of the (2) witness members could not corroborate this claim. (W1) believes that (R1's) urinary tract infection (UTI) contributes to (R1's) inaccurate reporting of the incident. (W1) stated that there has been no neglect or abuse in the care provided, and that the facility is delivering standard care. (W2) noted that (R1) showed no signs of cuts or injuries during the medical intake assessment.

Based on the information gathered, there is enough evidence to support the allegation mentioned above.

Allegation #2: Staff do not change residents timely.

The complaint alleges that the staff failed to change Resident #1 (R1) in a timely manner. It reported there is a delay in care for diaper changes and cleaning for (R1). No additional information about the incident has been provided.

On June 5, 2026, between 09:30 AM and 01:25 PM, the Department interviewed staff members identified as Staff #1 through Staff #3. Three (3) out of the three (3) staff members could not validate this claim. (S1-S3) stated that (R1) receives proper assistance with toileting and bathing. (S1-S2) explained that (R1's) diapers are changed three to four times daily or as needed. Additionally, (S1-S2) mentioned that the facility maintains progress notes listing the services provided daily by the time spent with (R1). These notes also document instances where (R1) has refused diaper changes and medications.

On June 5, 2026, between 9:45 AM and 10:25 AM, the Department interviewed resident members identified as Resident #2 through Resident #5 (R2-R5). Five (5) out of the (5) five residents cannot validate this claim. All reported satisfaction with the care and supervision provided by the staff, stating that it is adequate and that the staff is responsive.

On June 5, 2026, between 10:40 AM and 11:23 AM, the Department interviewed resident member identified as Resident #1 (R1) at Torrance Memorial Hospital. (R1) stated this claim is false. (R1) reported no issues with the timeliness of staff services. In fact, (R1) admitted to refusing diaper changes at night to avoid disrupting sleep, even if it meant dealing with soiled diapers. (R1) also stated to have no concerns with bathing as (R1) prefers sponge bathing.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20260601151344

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: DIVINE LIFE GUEST HOME	FACILITY NUMBER: 198320397
	VISIT DATE: 06/05/2026

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

On June 5, 2026, between 11:32 AM and 12:32 PM, the Department interviewed witness members identified as Witness #1 (W1). (W1) believes the staff is providing appropriate care and confirms that there is no neglect.

The Department reviewed the following records for this complaint: (R1’s) Physician’s Report LIC 602A (dated 05/29/25), Identification and Emergency Information LIC 601 (dated 05/29/25) Medication Profile (dated 12/01/25), Appraisal/Needs and Services Plan LIC 625 (dated 05/29/25), Admissions Agreement (dated 07/29/25), Unusual Incident Report LIC 624 (dated 05/30/26) Facility Progress Notes (dated 05/02/26 – 05/30/26), Torrance Memorial Medical Assessment (dated 05/31/26), Personnel Report LIC 500 (dated 04/25/23) and Register of Facility Residents LIC 9020 (dated 07/22/25).

Based on the information gathered, there is enough evidence to support the allegation mentioned above.

Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated.

No deficiencies were cited.

An exit interview was conducted with RODRIGO ROSALDO, and copies of the reports were provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:	DATE: 06/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 4