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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198601976
Report Date: 09/04/2025
Date Signed: 09/04/2025 04:57:37 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
08/28/2025 and conducted by Evaluator Mary G Flores
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250828081551
FACILITY NAME:DEL MAR PARKFACILITY NUMBER:
198601976
ADMINISTRATOR:RABIE BANAFSHEHAFACILITY TYPE:
740
ADDRESS:990 EAST DEL MAR BOULEVARDTELEPHONE:
(626) 577-0215
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY:124CENSUS: 66DATE:
09/04/2025
UNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Denise Sutton - Medical CoordinatorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff are not following admissions agreement.
Staff are unable to communicate with resident due to language barrier.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding above allegations. LPA met with Denise Sutton Medical Coordinator and Dana Perez Resident Service Coordinator and explained the reason for the visit.

The investigation consisted of the following: LPA requested a copy of resident/staff roster, conducted a tour of the facility and observed 3 resident room and dining area. LPA interviewed 6 residents and 6 staff and requested a copy of admission agreement, physician’s report, preplacement appraisal, pharmacy invoice, and letter dated 8/25/25 for resident #1(R1).

Regarding allegation: Staff are not following admission agreement. It is alleged resident is not being allowed to stay in assigned room per admission agreement. Interviews with residents revealed 5 out of 6 residents have not had issues with their room accommodations. 1 out of 6 residents stated they were asked to move out of their room and they did not wish to switch rooms, and it was done the same day the resident was notified. (CONTINUED ON LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
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 7
Control Number 28-AS-20250828081551
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: DEL MAR PARK
FACILITY NUMBER: 198601976
VISIT DATE: 09/04/2025
NARRATIVE
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Interviews with staff revealed resident was notified in writing on 8/25/25 that they will be switching R1 from rooms due to the need of the room to accommodate another resident with greater needs. On 8/29/25, Medical Coordinator went to R1’s room and notified R1 that they will be assisting R1 to move rooms that day and was moved within the hour. Per Document review dated 8/25/25 R1 was notified that they will be moved to another room on the first floor due to the need of space in current room and the move will take place on 9/6/25. Admission agreement signed 7/31/25 notes assigned room for R1 and notes transfer will be based on health and safety concerns of either resident. However, it does not note the transfer will take place on the same day. Based on the information provided, the notice, and the admission agreement reviewed, R1 was moved out of the room prior to the date on the notice. Therefore, this allegation is substantiated.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

Regarding allegation: Staff are unable to communicate with resident due to language barrier. It is alleged resident cannot communicate with staff as they do not speak English. Interviews with residents revealed 6 out of 6 residents stated that a few staff are not able to communicate with them when providing care due to the language barrier. However, they provide good care for them. Interviews with staff revealed there are a few staff, mostly the newer staff that cannot communicate in English and require assistance from other staff to communicate with the residents. LPA conducted interviews with staff in English during this visit. Per management team they do have a few staff that use their phone or other means to communicate with the residents.
Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview was conducted with staff and a copy of this report, LIC 9099D, and appeal rights were provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 28-AS-20250828081551
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: DEL MAR PARK
FACILITY NUMBER: 198601976
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/04/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
09/05/2025
Section Cited
CCR
87568.1(a)(6)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facility (a) In addition...shall have all of the following personal rights: (6) To make choices concerning their daily lives in the facility.

This requirement is not met as evidence by:
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Administrator will certify that they will ensure admission agreement and notices are followed by staff by POC due date 9/5/25.
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Based on interviews and documents reviewed licensee did not ensure admission agreement for R1 was followed and was moved before notice day which poses an immediate risk to the health, safety, or personal rights of the persons in care.
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Type B
09/18/2025
Section Cited
CCR
87411(d)(3)
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87411 Personnel Requirements - General (d) All personnel shall be given ... shall provide knowledge of and skill in the following, ..: (3) Skill and knowledge required to provide,... including the ability to communicate with residents.
This requirement is not met as evidence by:
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Administrator will submit a plan to ensure hiring and all staff are able to communicate with residents in care by POC due date 9/18/25.
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Based on interviews conducted licensee did not ensure staff are able to communicate wtih residents in care which poses a potential risk to the health, safety, or personal rights of the persons in care.
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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: Wei Siew Ho
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
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
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
08/28/2025 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20250828081551

FACILITY NAME:DEL MAR PARKFACILITY NUMBER:
198601976
ADMINISTRATOR:RABIE BANAFSHEHAFACILITY TYPE:
740
ADDRESS:990 EAST DEL MAR BOULEVARDTELEPHONE:
(626) 577-0215
CITY:PASADENASTATE: CAZIP CODE:
91106
CAPACITY:124CENSUS: 66DATE:
09/04/2025
UNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Denise Sutton Medical Coordinator TIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff speak to residents in an inappropriate manner.
Staff are denying resident's request to share a room.
Staff are not providing adequate food service.
Staff do not accord resident privacy.
Staff are withholding resident's with assigned keys.
Staff are overcharging resident.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced complaint investigation visit regarding above allegations. LPA met with Denise Sutton Medical Coordinator and Dana Perez Resident Service Coordinator and explained the reason for the visit.

The investigation consisted of the following: LPA requested a copy of resident/staff roster, conducted a tour of the facility and observed 3 resident room and dining area. LPA interviewed 6 residents and 6 staff and requested a copy of admission agreement, physician’s report, preplacement appraisal, pharmacy invoice, and letter dated 8/25/25 for resident #1(R1).

The investigation revealed the following: Regarding allegation: Staff speak to residents in an inappropriate manner. It is alleged staff spoke to resident inappropriate and yelled at a resident.

(CONTINUED ON LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
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 28-AS-20250828081551
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: DEL MAR PARK
FACILITY NUMBER: 198601976
VISIT DATE: 09/04/2025
NARRATIVE
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Interviews conducted with residents revealed 4 out of 6 residents stated staff speak to them respectfully and do not yell. 2 out of 6 residents stated a staff member has been disrespectful to them when speaking to them, not yelling but disrespectful. Interviews with staff revealed that staff are respectful when speaking to the residents and have not witness staff yelling or being disrespectful to the residents in care.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Regarding allegation: Staff are denying resident's request to share a room. Interviews conducted with residents revealed 4 out of 6 residents have a private room and have no concerns or requested to have a shared room. 2 out of 6 residents have or had a shared room, 1 resident stated that they are aware they will be sharing a room with a roommate and had a roommate until recently. Another resident stated that they are concern that they won’t be able to fit their belongings in a different room when needing to share the room as the previous room was large enough to accommodate their belongings. Interviews with staff revealed currently the rooms at the facility are shareable and accommodation is provided to ensure both residents are comfortable when sharing. Per Medical Coordinator and Resident Coordinator, R1 was temporarily moved into a room without a roommate due to accommodation for a resident with greater needs needed to be made. However, once there is a need for R1’s current room to have a roommate, R1 will have a roommate. Per notice provide to R1 on 8/25/25 it notes that for a “short period of time … would be the only occupant.” Although R1 was moved alone to a room, R1 could have a roommate eventually. Therefore, this allegation is unsubstantiated.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Regarding allegation: Staff are not providing adequate food service. It is alleged resident is not provided with a place to sit in the dining room to eat their meals. Interviews conducted with residents revealed 5 out of 6 residents stated there is sufficient space and a space for them to always seat during their meals. 1 out of 6 residents stated that on an occasion they found their usual/assigned dining space occupied and they decided to walk out of the dining room. Interviews with staff revealed there is sufficient seating area for the residents to have their meals. Per Resident Service Coordinator, assignment of seats during meals had been rearranged due to residents not getting along. However, there is always open space for residents to have their meals during mealtimes. During facility’s tour LPA observed a large dining room with tables and chairs available for meals. (CONTINUED ON LIC 9099C)
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 28-AS-20250828081551
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: DEL MAR PARK
FACILITY NUMBER: 198601976
VISIT DATE: 09/04/2025
NARRATIVE
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Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Regarding allegation: Staff do not accord resident with privacy. It is alleged staff walk into residents’ room without knocking. Interviews conducted with 5 out of 6 residents revealed staff knocks before entering their rooms. 1 out of 6 residents stated there is one staff member who does knock. However, this staff enters the room without waiting for the residents to respond. Interviews with staff revealed staff knock at residents’ door prior entering their room. LPA observed 1 staff knocking at a resident’s room before entering the room and observed a staff calling out to the resident prior entering the resident room as the resident’s door was open.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Regarding allegation: Staff are withholding resident’s assigned keys. It is alleged facility staff has not provided resident with a key to the room. Interviews conducted with 4 out of 6 residents revealed residents have been provided with a key to their rooms and mailbox. 2 out of 6 residents stated not to have a key to their rooms. However, 1 of the 2 stated that they didn’t need a key as they are not able to use it. 1 out of the 2 residents stated that they were recently provided with a mailbox key but no room key. Interviews with staff revealed that residents are provided with a key upon admission. Per medical coordinator, R1 was provided a key to the mailbox on 9/2/25 and a key to the room on 9/4/25 for the new room that R1 was moved to on 8/29/25 due to the long weekend accommodations to obtain a key sooner was not available. Also, a key to the previous room would have been provided by the marketing employee, who is no longer employed at the facility. Although a key was provided a few days after the resident moved into a new room. There is no evidence that a key was not provided for the previous room or documents that note a key was provided. Therefore, the allegation is unsubstantiated.
Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

(CONTINUED ON LIC 9099C)
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 28-AS-20250828081551
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: DEL MAR PARK
FACILITY NUMBER: 198601976
VISIT DATE: 09/04/2025
NARRATIVE
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Regarding allegation: Staff are overcharging resident. It is alleged resident is being charged for prescription fees. Interviews with residents revealed 5 out of 6 residents stated to not have had additional charges or pharmacy charges from the facility. 1 out of 6 residents stated to have received a statement dated 8/14/25 from the facility’s contracted pharmacy for $4.80. Per resident they use their own pharmacy and do not use the services of the pharmacy that sent the invoice. Interviews with staff revealed R1 had made them aware of the invoice, and they contacted their contracted pharmacy. Resident Service Coordinator stated to have requested a profile only from the pharmacy. However, they did not request medications and pharmacy processed them. After the Resident Service Coordinator contacted the pharmacy, they corrected the error and provide an invoice with no balance.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with staff and a copy of this report was provided.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Mary G Flores
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7