198320600-7-20-2026-11-AS-JHAD-DWNN9T-20260805101629

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320600
Report Date: 07/20/2026
Date Signed: 07/20/2026 02:37:34 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
11/12/2025 and conducted by Evaluator Jose Anguiano

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20251112145542

FACILITY NAME:	LADERA SUNRISE CARE HOME		FACILITY NUMBER:	198320600
ADMINISTRATOR:	ERONOBI, KELECHI		FACILITY TYPE:	740
ADDRESS:	6017 S CROFT AVE		TELEPHONE:	(310) 848-8153
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90056
CAPACITY:	6	CENSUS: 5	DATE:	07/20/2026
		UNANNOUNCED	TIME BEGAN:	01:23 PM
MET WITH:	Kelechi Eronobi		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Due to staff neglect, resident sustained multiple pressure injuries

INVESTIGATION FINDINGS:

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On 07/20/2026 around 1:00 PM, Licensing Program Analyst (LPA) Jose Anguiano conducted a subsequent unannounced visit to deliver findings. LPA met with the Administrator Kelechi Eronobi.

The investigation consisted of the following: On 11/13/2025 The investigation included a tour of the facility. The Department collected: Register of Facility Residents, Resident (R1–R2) records. Register of clients, a pressure ulcer/decubitus sore prevention and care training handout, weekly staff schedule. On 01/07/2026 The Department conducted interviews with Staff S1–S4 and one witness (W-2) and attempted to interview R2, R3, and R4. And collected additional records for R1 and R2. Including mobility support and comfort training, pressure ulcer care plan, pressure ulcer bedsore prevention care plan, hospice plan of care for resident R2, 30-day feeding/meal intake log for R1–R2, repositioning logs dated from 05/01/2025 through 11/10/2025 R1, and physician’s report for R1.
Please see report continuation on (LIC9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Anguiano
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2026

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

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
11/12/2025 and conducted by Evaluator Jose Anguiano

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20251112145542

FACILITY NAME:	LADERA SUNRISE CARE HOME		FACILITY NUMBER:	198320600
ADMINISTRATOR:	ERONOBI, KELECHI		FACILITY TYPE:	740
ADDRESS:	6017 S CROFT AVE		TELEPHONE:	(310) 848-8153
CITY:	LOS ANGELES	STATE:CA	ZIP CODE:	90056
CAPACITY:	6	CENSUS: 5	DATE:	07/20/2026
		UNANNOUNCED	TIME BEGAN:	01:23 PM
MET WITH:	Kelechi Eronobi		TIME COMPLETED:	02:50 PM

ALLEGATION(S):

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Due to staff neglect resident lost weight

INVESTIGATION FINDINGS:

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On 07/20/2026 around 1:00 PM, Licensing Program Analyst (LPA) Jose Anguiano conducted a subsequent unannounced visit to deliver findings. LPA met with the Administrator Kelechi Eronobi.
The investigation consisted of the following: On 11/13/2025 The investigation included a tour of the facility. The Department collected: Register of Facility Residents, Resident (R1–R2) records. Register of clients, a pressure ulcer/decubitus sore prevention and care training handout, weekly staff schedule. On 01/07/2025 The Department conducted interviews with Staff S1–S4 and one witness (W-2) and attempted to interview R2, R3, and R4. And collected additional records for R1 and R2. Including mobility support and comfort training, pressure ulcer care plan, pressure ulcer bedsore prevention care plan, hospice plan of care for resident R2, 30-day feeding/meal intake log for R1–R2, repositioning logs dated from 05/01/2025 through 11/10/2025 R1, and physician’s report for R1. On 02/27/2026 the Department reviewed hospital records dated from (11/10/2025–11/14/2025)
Please see report continuation on (LIC9099-C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Anguiano
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2026

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

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 11-AS-20251112145542

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: LADERA SUNRISE CARE HOME	FACILITY NUMBER: 198320600
	VISIT DATE: 07/20/2026

NARRATIVE

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The investigation revealed the following: Regarding the allegation “Due to staff neglect resident lost weight”. Interviews conducted revealed the following: 4 out of 4 staff disagreed with the allegation S4 noted that R1’s decreased food intake appeared related to advanced age. 1 witness agreed (W1), and 1 witness disagreed (W3). S3 stated that R1 began refusing food and required blended meals.
Records review revealed the following: Hospital records dated 11/10/2025 document that R1 had decreased appetite and appeared underweight, with a recorded weight of 101 lbs. and pureed diet intake ranging from 30% to 50% during the hospitalization.
Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation “Due to staff neglect resident lost weight” may have happened or is 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, and a copy of this complaint report was given to the Administrator.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Anguiano
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 11-AS-20251112145542

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: LADERA SUNRISE CARE HOME	FACILITY NUMBER: 198320600
	VISIT DATE: 07/20/2026

NARRATIVE

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On 02/27/2026 the Department reviewed hospital records dated from (11/10/2025–11/14/2025).
The investigation revealed the following:
Regarding the allegation “Due to staff neglect, resident sustained multiple pressure injuries it is being alleged that resident sustained multiple pressure injuries due to staff not turning R1.
Interviews conducted revealed the following: 4 out of 4 staff disagreed with the allegation. 2 Witnesses agreed (W1- W2) with the allegation Witnesses (W3) disagreed. W4 last visited R1 on 10/18/25, and (S1) declined further services. The Department attempted to interview R2, R3, and R4 but the residents could not provide interviews due to their inability to verbally communicate. R1 was not in the facility and as a result was not interviewed.
Record reviews revealed the following: The facility’s register of clients indicates R1 was admitted into the facility on 06/30/2024, and the physician’s report from that date documents no pressure injuries. R1 later developed a Stage 3 sacral ulcer by May 2025 while on hospice, with wound care notes continuing through 10/19/2025. Advance Wound Care Specialist notes home visit orders show ongoing wound care treatment through 10/19/2025, R1 was last noted to have a Stage 3 sacral pressure injury as of the 10/19/2025 progress note. From 10/20/2025 until R1’s hospitalization on 11/10/2025, facility records show no professional wound-care, home health, or hospice services were provided. Department records indicate that on 11/17/2025, it was reported that on 11/09/2025 (R1) was observed to be severely malnourished and was found with multiple wounds on body. It was also reported that wound care services had stopped due to unpaid copays. Cedars Sinai Marina Del Rey Hospital records dated 11/09/2025 revealed R1 being hospitalized with multiple community acquired pressure injuries, including a Stage 4 sacral ulcer with exposed muscle and bone, and unstageable pressure injuries to both hips and both knees. Plastic surgery performed sharp excisional debridement of the sacral ulcer down to muscle and fascia after consent from the healthcare proxy, and wound care staff recommended local wound care, offloading, and continued treatment. R1 was also diagnosed with sepsis secondary to a urinary tract infection, maintained on a pureed heart healthy diet, and was determined to require skilled nursing placement for ongoing wound care and rehabilitation.
Based on interviews conducted and records reviewed, the facility staff failed to ensure R1’s wounds were properly cared for by not ensuring that wound care was provided for approximately one month, during which R1’s wounds progressed to stage four. The preponderance of evidence standard has been met; therefore, the above-mentioned allegation is found to be SUBSTANTIATED.
Please see report continuation on (LIC9099-C)

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Anguiano
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 11-AS-20251112145542

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: LADERA SUNRISE CARE HOME	FACILITY NUMBER: 198320600
	VISIT DATE: 07/20/2026

NARRATIVE

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This is a violation of California Code of Regulations, Title 22, Division 6, Chapter 8. A citation is being issued on the attached (LIC-9099D). An immediate civil penalty is being issued; please see (LIC421IM).
At this time, a additional civil penalty determination is pending in reference to The Welfare and Institutions Code Section 15610.67 which defines serious bodily injury as “an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.”

An exit interview was conducted, and plans of corrections were developed with Administrator. And a copy of this report and appeal rights were provided to the Administrator.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Anguiano
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 11-AS-20251112145542

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: LADERA SUNRISE CARE HOME	FACILITY NUMBER: 198320600
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/20/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/21/2026 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...specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.	1 2 3 4 5 6 7	Licensee agreed to submit a written Plan of Correction to LPA Jose Anguiano at Jose.Anguiano@dss.ca.gov within 24 hours of receipt of this report.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on records and interviews, the licensee retained R1 in care despite R1 having a Stage 4 sacral pressure injury. This violation posed an immediate health, safety, and personal rights risk to people in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Anguiano
LICENSING EVALUATOR SIGNATURE:	DATE: 07/20/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/20/2026

LIC9099 (FAS) - (06/04)

Page: 6 of 6