198320508-8-7-2026-11-AS-JHAD-DWTLGX-20260810084528

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320508
Report Date: 08/07/2026
Date Signed: 08/07/2026 05:08:45 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
11/26/2025 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20251126152629

FACILITY NAME:	ACE ELDERLY HOMES		FACILITY NUMBER:	198320508
ADMINISTRATOR:	LIWANAG, FRANCIS		FACILITY TYPE:	740
ADDRESS:	23223 PRYOR PLACE		TELEPHONE:	(310) 985-1059
CITY:	HARBOR CITY	STATE: CA	ZIP CODE:	90710
CAPACITY:	6	CENSUS: 6	DATE:	08/07/2026
		UNANNOUNCED	TIME BEGAN:	01:07 PM
MET WITH:	FRANCES LIWANAG		TIME COMPLETED:	03:37 PM

ALLEGATION(S):

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Staff neglect resulting in unstageable pressure injuries.

INVESTIGATION FINDINGS:

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On August 7, 2026, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA), Ernand Dabuet, conducted a subsequent unannounced complaint visit. FRANCES LIWANAG, Administrator, greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegation mentioned above.

The investigation included interviews, record reviews, and a tour of the facility. Investigator Dennis Douglas of the CDSS Investigation Branch conducted the investigation. Interviews with Staff member S#1 - S#5 (S1-S5), Witness #1 and #2 (W1-W2), attempted Witness #3 and Witness #4 (W3-W4), (R1’s) Admissions Agreement (dated 03/17/25), Physician’s Report LIC 602A (dated 03/25/25), Preplacement Appraisal Information (dated 03/17/26), County of Los Angeles Certificate of Death (dated 05/28/26), Unusual Incident Report LIC 624 (dated 09/09/26 and 11/26/25), Kaiser Permanente South Bay Medical Center Discharge Report (dated 09/09/25), Harbor UCLA Medical Center Medical Records, and Summerwind Hospice Plan of Care (dated 11/05/25). . (Evaluation Report continues LIC 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
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 7

Control Number 11-AS-20251126152629

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: ACE ELDERLY HOMES	FACILITY NUMBER: 198320508
	VISIT DATE: 08/07/2026

NARRATIVE

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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: Staff neglect resulting in unstageable pressure injuries.

It is alleged that the staff's neglect of Resident #1 (R1) led to unstageable pressure injuries. Reports indicate that (R1) was hospitalized, and a medical examination revealed multiple wounds. Specifically, there is a 7 cm by 5 cm sacrococcygeal deep pressure tissue injury, an unstageable scapular wound measuring 3 cm by 2 cm with full-thickness tissue loss and necrotic tissue, and a 1 cm by 1 cm unstageable ankle wound with full-thickness tissue loss and eschar. No further information has been provided regarding this matter.

On January 2, 2026, January 23, 2026, and February 27, 2026, between 08:00 AM and 02:30 PM, the Department conducted interviews with staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the five (5) staff confirmed that Resident #1 (R1) developed pressure injuries while in their care. According to (S1, S4, and S5), (R1) arrived at the facility on March 21, 2025, without any pressure injuries and showed no signs of such injuries, including the one that later developed on the upper mid-back.

Throughout (R1's) residency, staff observations from (S1, S4, and S5) indicated a decline in (R1's) condition. (R1) exhibited a loss of motivation to walk, increasing weakness, and a tendency to remain in bed throughout the day. Despite being repositioned every two hours, (S2 and S3) noted that (R1) still developed pressure injuries while in care. Additionally, (S1 and S5) reported noticing redness on (R1's) back starting in August 2025, which later progressed into a pressure injury. By the time hospice care began on November 5, 2025, the injury had progressed to stage III.

On February 24, 2026, March 2, 2026, and May 5, 2026, between 09:35 AM and 4:10 PM, the Department interviewed witness identified as Witness #1 (W1). (W1) reported that (R1) went into "septic shock" from an "unstageable" pressure wound that developed at the facility, where (R1) was not receiving hospice care. During the last four weeks, care was provided while (R1) was seated in a recliner, worsening the wound.

On February 24, 2026, and May 05, 2026, between 03:25 PM and 04:10 PM, the Department interviewed witness identified as Witness #2 (W2). (W2) stated that (R1) had passed away on December 7, 2025, and advised contacting (W1) for further information on the matter.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
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 7

Control Number 11-AS-20251126152629

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: ACE ELDERLY HOMES	FACILITY NUMBER: 198320508
	VISIT DATE: 08/07/2026

NARRATIVE

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The Department attempted to interview Witness #3 and Witness #4, but phone messages went unanswered, and they were unavailable for an interview.

The Department could not interview Resident #1 (R1) because (R1) has passed away.

The Department reviewed (R1’s) Admissions Agreement (dated 03/17/25), Physician’s Report LIC 602A (dated 03/25/25), Preplacement Appraisal Information (dated 03/17/26), Summerwind Hospice Plan of Care (dated 11/05/25), Unusual Incident Report LIC 624 (dated 09/09/26 and 11/26/25), Kaiser Permanente South Bay Medical Center Discharge Report (dated 09/09/25), Harbor UCLA Medical Center Medical Records, and County of Los Angeles Certificate of Death (dated 05/28/26).

Based on all the information collected, the allegation of neglect and lack of care and supervision regarding (R1) has been confirmed to have developed a stage III pressure injury by the time hospice care service was initiated, and the facility kept the resident despite having a Prohibited Health Condition without an established wound care plan. There is sufficient evidence to corroborate the allegation.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiency was observed, and citation issued (ref. LIC 9099 D).

An exit interview was conducted with FRANCES LIWANAG, and copies of the report and appeal rights were provided.

*Immediate Civil Penalty issued*

ECP: At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(f) For a violation that the department determines constitutes physical abuse, as defined in Section 15610.63 of the Welfare and Institutions Code, or resulted in serious bodily injury, as defined in Section 15610.67 of the Welfare and Institutions Code, to a resident, the civil penalty shall be ten thousand dollars ($10,000).

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
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 7

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
11/26/2025 and conducted by Evaluator Ernand Dabuet

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20251126152629

FACILITY NAME:	ACE ELDERLY HOMES		FACILITY NUMBER:	198320508
ADMINISTRATOR:	LIWANAG, FRANCIS		FACILITY TYPE:	740
ADDRESS:	23223 PRYOR PLACE		TELEPHONE:	(310) 985-1059
CITY:	HARBOR CITY	STATE:CA	ZIP CODE:	90710
CAPACITY:	6	CENSUS: 6	DATE:	08/07/2026
		UNANNOUNCED	TIME BEGAN:	01:07 PM
MET WITH:	FRANCES LIWANAG		TIME COMPLETED:	03:37 PM

ALLEGATION(S):

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Staff did not seek timely medical attention for resident.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
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: 4 of 7

Control Number 11-AS-20251126152629

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: ACE ELDERLY HOMES	FACILITY NUMBER: 198320508
	VISIT DATE: 08/07/2026

NARRATIVE

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The Department could not interview Resident #1 (R1) because R1 has passed away.

The Department reviewed (R1’s) Admissions Agreement (dated 03/17/25), Physician’s Report LIC 602A (dated 03/25/25), Preplacement Appraisal Information (dated 03/17/26), County of Los Angeles Certificate of Death (dated 05/28/26), Unusual Incident Report LIC 624 (dated 09/09/26 and 11/26/25). Further review of Kaiser Permanente South Bay Medical Center Discharge Report (dated 09/09/25), Harbor UCLA Medical Center Medical Records, and Summerwind Hospice Plan of Care (dated 11/05/25) revealed no document a hip fracture.

Based on the gathered information, it appeared that the facility was unaware of falls that resulted in a hip fracture involving Resident #1 (R1) and that, when medical crises occurred, the facility acted promptly to seek medical attention. There is insufficient evidence to corroborate the allegation.

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

No deficiencies cited.

An exit interview was conducted with FRANCES LIWANAG, and copies of the reports were provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
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 7

Control Number 11-AS-20251126152629

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: ACE ELDERLY HOMES	FACILITY NUMBER: 198320508
	VISIT DATE: 08/07/2026

NARRATIVE

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Allegation #2: Staff did not seek timely medical attention for resident.

It is alleged that staff failed to seek timely medical attention for Resident #1 (R1). Reports indicate that (R1) was admitted to Harbor UCLA Medical Center with septic shock resulting from pneumonia, as well as a newly discovered hip fracture. Further reports mentioned that the newly discovered hip fracture went unreported, and the facility did not seek timely medical care for (R1). No additional information has been provided regarding this matter.

On January 2, 2026, January 23, 2026, and February 27, 2026, between 08:00 AM and 02:30 PM, the Department conducted interviews with staff members identified as Staff #1 through Staff #5 (S1-S5). Five (5) out of the five (5) staff are unable to corroborate this allegation. On November 26, 2025, (R1) was admitted to the hospital due to significant shortness of breath. There were no indications of fractures, as confirmed by (S1) and (S5). Before this hospitalization, all staff members who interacted with (R1) reported no falls, except for a single incident on September 9, 2025, which resulted in a head injury, but again, there were no fractures.

After the head injury, emergency services were promptly dispatched, and (R1) received timely medical attention at Kaiser Permanente and was discharged the same day, September 9, 2025. (S1) reported that on September 9, 2026, while (R1) was outside in the backyard with staff, (R1) lost balance as (R1) was about to step onto the grass and fell, hitting (R1's) head on (R1's) reading glasses, which caused a wound. 911 was called, and staff were instructed to apply pressure to the wound to stop the bleeding. (S1-S5) confirmed that the facility sought immediate medical attention for (R1) following this fall incident.

On February 24, 2026, March 2, 2026, and May 5, 2026, between 09:35 AM and 4:10 PM, the Department interviewed witness identified as Witness #1 (W1). During the interview, (W1) did not mention (R1) sustaining fractures and only commented on a lack of proper care.

The Department attempted to interview Witness #3 and Witness #4, but phone messages went unanswered, and they were unavailable for an interview.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
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: 5 of 7

Control Number 11-AS-20251126152629

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: ACE ELDERLY HOMES	FACILITY NUMBER: 198320508
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/07/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/08/2026 Section Cited CCR 87615(a)(1)	1 2 3 4 5 6 7	87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator will review Title 22, Section 87615, and the Plan of Operation to ensure compliance. The Licensee will retrain staff on pressure injuries and submit the completed training, including staff names and completion dates, to ernand.dabuet@dss.ca.gov by the POC date of 08/08/26.
	8 9 10 11 12 13 14	Based on interviews, observations, and record reviews, Licensee was aware of (R1's) pressure injuries, which developed to Stage 3, which are prohibited health conditions, and did not have a wound care plan or hospice care. This violation poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	CIVIL PENALTY
Type B 08/28/2026 Section Cited CCR 87463(B)	1 2 3 4 5 6 7	87463 Reappraisals (b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator will review Title 22, Section 87463, and the Plan of Operation to ensure compliance. The Licensee will retrain staff on identifying residents' change in condition, including staff names and completion dates, to ernand.dabuet@dss.ca.gov by the POC date of 08/28/26.
	8 9 10 11 12 13 14	Based on interviews, observations, and record reviews, the licensee was aware of R1's change in condition, as R1's health had declined, and did not do a reappraisal for R1. This violation poses a potential health and safety risk to residents 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: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
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)

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