198320429-5-15-2026-11-AS-UCOL-DVTVSM-20260709164145

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320429
Report Date: 05/15/2026
Date Signed: 05/15/2026 01:28:15 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
10/28/2025 and conducted by Evaluator Mario Leon

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20251028151606

FACILITY NAME:	ETHEL'S GUEST HOME		FACILITY NUMBER:	198320429
ADMINISTRATOR:	MONTERROSO, ETHEL JANE		FACILITY TYPE:	740
ADDRESS:	1730 W 1ST STREET		TELEPHONE:	(310) 634-7522
CITY:	SAN PEDRO	STATE: CA	ZIP CODE:	90732
CAPACITY:	6	CENSUS: 5	DATE:	05/15/2026
		UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Ethel Monterroso - Licensee		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Staff did not prevent resident from developing a pressure injury

INVESTIGATION FINDINGS:

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On 05/13/26 Licensing Program Analyst (LPA) Mario Leon delivered findings regarding the allegation above. California Department of Social Services (CDSS) was met by staff one, Ethel Monterroso (S1) and the purpose of the visit was explained.
The investigation consisted of the following:
On 10/29/25 CDSS toured the facility, along with S1, and requested a resident roster (dated: 09/22/25) and staff roster (dated:10/29/25). LPA collected two resident's (R1 & R2) paperwork, listed as follows: Admissions agreements (dated: 08/01/24 & 01/14/25), medical assessments (dated: 08/07/23 & 01/15/24), emergency identification forms (dated: 08/01/23 & 01/14/24), appraisal needs and services (dated: 08/01/23 & 01/13/25) and medical consent forms (dated: 08/01/23 & 01/13/25). On 05/12/26 CDSS collected further records from the hospice services of R1, death certificate of R1 and CDSS interviewed three (3) staff (S1-S3), one (1) family witness (W1) and one (1) hospice nurse (W2) and two (2) out of five (5) residents (R2 & R3). Residents four through five were not available (R4-R5) for interview due to medical condition.
Report continues, please see LIC9099-C

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20251028151606

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: ETHEL'S GUEST HOME	FACILITY NUMBER: 198320429
	VISIT DATE: 05/15/2026

NARRATIVE

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The investigation revealed the following:

Regarding the allegation “Staff did not prevent resident from developing a pressure injury”, it is being alleged that a resident (R1) was admitted on 10/25/25, with a stage 3 or greater Sacral Gluteal wound with necrotic tissue due to staff neglect. Record reviews revealed that on 10/29/25 R1 was being provided hospice services by Loyalty Hospice Services, Inc. On 11/01/25 R1 was admitted to Los Palos Post-Acute Care Center and was receiving Physical Therapy and Occupational Therapy and that R1 responded well to skilled services. On 05/12/25 LPA observed staff responding to requests from five (5) residents and two (2) family members visiting with their responsible person(s). Interviews revealed that two (2) out of three (3) staff were unfamiliar with R1, while one (1) out of three (3) staff disagreed with the allegation. One (1) family witness (W1) and one (1) hospice nurse (W2), along with two (2) out of two (2) residents, disagreed with the allegation. Based on observation, record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

There have been zero (0) deficiencies cited during today's visit.

An exit interview was held with staff one, Ethel Monterroso - Licensee (S1), and a copy of this report has been provided.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2026

LIC9099 (FAS) - (06/04)

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