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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601953
Report Date: 06/07/2025
Date Signed: 06/07/2025 12:42:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/29/2025 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250429162024
FACILITY NAME:KENSINGTON SIERRA MADRE, THEFACILITY NUMBER:
198601953
ADMINISTRATOR:CECILIA DEGRAFFFACILITY TYPE:
740
ADDRESS:245 W. SIERRA MADRE BLVD.TELEPHONE:
(626) 355-5700
CITY:SIERRA MADRESTATE: CAZIP CODE:
91024
CAPACITY:106CENSUS: 90DATE:
06/07/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Daniel Orozco and and April VargasTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Resident is being physically abused while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent visit to deliver findings on 06/07/2025 regarding the above allegation. LPA Ramirez conducted an unannounced subsequent investigation visit on 05/16/2025 to gather additional interviews and documents; a need further investigation was documented. On 05/08/2025, LPA Ramirez conducted initial investigation, and a need further investigation was documented. During today’s visit, LPA Ramirez was greeted by Daniel Orozco and April Vargas and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff roster, Staff#1 - 10 interviews (S1 – S10), Attempted interview of Residnet#1(R1), Interview with R1’s Responsible party, Copies of email statements from staff, Copies of S1, S4, S6, S8, S9- Employment application, Copies of various trainings completed by S1, Copies of R1’s: Physician’s Report, Physician Orders, Facility resident appraisal, Staff charting notes, Employment Termination Letter for S1, Copy of Sierra Madre Police Incident Report, and physical plant tour. SEE 9099-C for continued report.
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2025
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 28-AS-20250429162024
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: KENSINGTON SIERRA MADRE, THE
FACILITY NUMBER: 198601953
VISIT DATE: 06/07/2025
NARRATIVE
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The investigation revealed the following: regarding the allegation “Resident is being physically abused while in care.” It is alleged facility staff are abusing residents in the dementia wing of the facility. According to staff interviews conducted by LPA Ramirez, S1 was observed pushing resident R1 down into their bed, handled residents roughly during dressing and forcefully sat them down. Additionally, S1 was seen being dismissive and diminishing towards R1, saying “you’re not the princess”. Staff interviews did not reveal any residents were injured as a result of S1’s conduct. Record reviewed by LPA Ramirez did not reveal residents were injured as a result of S1’s conduct. Following an internal investigation, the facility terminated S1’s employment as of May 12, 2025. LPA Ramirez obtained a copy of Sierra Madre Police Incident Report dated 04/29/2025. This incident report did not corroborate this allegation. Interview with R1’s responsible party did not corroborate this allegation. Due to cognitive impairments, R1 was unable to provide a meaningful interview.

Based on interviews and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated. Per Title 22, Division 6, Chapter 8, Article 08 Resident Assessments, Fundamental Services and Right- 87468.1(a)(3)- Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. S1’s conduct poses an immediate threat to the physical health, mental health, or safety of residents in care. Therefore, LPA Ramirez will issue a Type A deficiency.



One (1) deficiency was cited for this complaint investigation. A copy of this report, 9099-D, and appeals rights was provided.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250429162024
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KENSINGTON SIERRA MADRE, THE
FACILITY NUMBER: 198601953
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
06/08/2025
Section Cited
CCR
87468.1(a)(3)
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Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding
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Administrator will certify a plan on when staff re-training will be conducted for ALL staff that provide direct care and supervision to residents and those who assist residents with activities of daily living. Certified plan must be emailed to LPA Ramirez by 06/08/25.
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residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirmenent was not met as evidenced by: S1 physically abused R1 which poses an immediate threat to the physical health, mental health, or safety of residents in care.
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Re-training shall cover regulation 87468.1(a)(3). Proof of re-training shall be emailed to LPA Ramirez by 06/18/25.
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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.
NAME OF LICENSING PROGRAM MANAGER: Fernando Fierros
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3