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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320398
Report Date: 05/29/2025
Date Signed: 05/29/2025 10:51:57 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
11/13/2024 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20241113165545
FACILITY NAME:PENINSULA POINTE BY COGIRFACILITY NUMBER:
198320398
ADMINISTRATOR:KITAGAWA, DESIREEFACILITY TYPE:
740
ADDRESS:27520 HAWTHORNE BOULEVARDTELEPHONE:
(310) 697-6236
CITY:ROLLING HILLS ESTATESTATE: CAZIP CODE:
90274
CAPACITY:121CENSUS: 42DATE:
05/29/2025
UNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Julius Osorio, Executive DirectorTIME COMPLETED:
11:19 AM
ALLEGATION(S):
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Facility staff caused bruising to resident in care
INVESTIGATION FINDINGS:
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On 05/29/25 Licensing Program Analyst (LPA) Mario Leon conducted a subsequent complaint investigation at the facility to deliver findings on the allegations listed above. LPA was met by Julius Osorio (S14), and the purpose of the visit was explained.
The investigation consisted of the following: On 11/14/2024 Licensing Program Manager (LPM) Ulysses Coronel and LPA obtained the following records: Staff Roster, Resident Roster, Staff schedule, five (5) staff records, two (2) resident records, three (3) incident reports and a surveillance record from SafelyYou. CCLD staff toured the facility, inside and out. CCLD interviewed Administrator, Desiree Kitigawa (S3) and resident one (R1). On 05/13/25 LPA interviewed witness (W1) and obtained hospital medical records, dated 11/11/24. On 05/14/25 LPA interviewed five (5) residents (R2-R6), one witness (W2), and six (6) staff (S8, S10 - S14). S1 and S2 were not available during the investigation.

Report Continues, see LIC9099-C.
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025
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-20241113165545
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: PENINSULA POINTE BY COGIR
FACILITY NUMBER: 198320398
VISIT DATE: 05/29/2025
NARRATIVE
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The investigation revealed the following: Regarding the allegation “Facility staff caused bruising to resident in care”, it is being alleged that a resident was bruised by staff while being redirected back to their room during an elopement. Record reviews indicate the following: Surveillance records (dated: 11/08/24) indicates that R1 was brought back to their room through a two-person carry by S1 and S2. S1 was carrying R1 by the legs and S2 was carrying R1 by the armpits, as the staff transported R1 back to their room. LPA observed S1 grasp R1's left elbow while S1 attempts to close R1's door, before redirecting R1, by the armpits, further into their room. Hospital Medical record (dated: 11/11/24) indicates that R1 was admitted at Torrance Memorial Medical Center (TMMC) on 11/11/24 at 3:25PM by ambulance, with bruising on R1’s upper extremities. Hospital Medical record included photography of R1’s upper extremities and armpits, which depicted three (3) purple marks on R1’s left forearm, three (3) purple marks on R1’s right forearm and bruising in R1’s armpits. Interviews revealed that S3 has agreed that Emergency Medical Services (911) should have been contacted after R1’s first elopement incident on 11/08/24.
Based on CCLD’s 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. Please see the attached LIC 9099D.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20241113165545
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: PENINSULA POINTE BY COGIR
FACILITY NUMBER: 198320398
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/06/2025
Section Cited
CCR
87468.1(a)(6)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in...care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night.
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The licensee and LPA have agreed that inservice training will be conducted with staff regarding personal rights of residents in all care facilities, with a focus on elopement procedures related to cognitively impaired residents.The training will also include a reminder of various redirection methods for
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This has not been met as evidenced by: The licensee did not ensure that staff would follow residents personal rights, resulting in bruising of a resident in care.
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safely redirecting a resident, when a resident presents exit seeking behavior, and when to contact Emergency Medical Services. This training information, sign-in sheet & time spent will be forwarded on or prior to POC due date to LPA, via email, at MARIO.LEON@DSS.CA.GOV
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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: 05/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025
LIC9099 (FAS) - (06/04)
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