198602216-8-18-2026-11-AS-EMAZ-DXASAM-20260825134233

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602216
Report Date: 08/18/2026
Date Signed: 08/18/2026 04:49:08 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/15/2026 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20260615182651

FACILITY NAME:	FRANCESCA'S HOME		FACILITY NUMBER:	198602216
ADMINISTRATOR:	COELLO, BESSIE L		FACILITY TYPE:	740
ADDRESS:	20520 AVIS AVENUE		TELEPHONE:	(310) 292-8425
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90503
CAPACITY:	6	CENSUS: 6	DATE:	08/18/2026
		UNANNOUNCED	TIME BEGAN:	04:26 PM
MET WITH:	Bessie Coello		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not administer medication as prescribed
Staff withhold meals from resident as a form of retaliation
Staff do not ensure that residents are provided a comfortable accomodations
Staff do not treat residents with dignity and respect
Staff not providing records to the authorized representative/resident

INVESTIGATION FINDINGS:

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On 08/18/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced subsequent Complaint Visit to the facility listed above. LPA met with Licensee, Bessie Coello, and the purpose of today’s visit was explained. LPA was granted entry into the facility.
The investigation consisted of the following:
During the initial visit conducted on 06/23/2026, LPA inspected the facility, interviewed Staff S1-S3, interviewed Residents R2-R6, interviewed Witnesses W1 and W2, and received and reviewed documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Identification & Emergency Information (dated 05/16/2026), Admission Agreement (dated 05/16/2026), Program Description (05/16/2026), Medication Procedures (dated 05/16/2026), House Rules (dated 05/16/2026), Personal Rights of Resident’s in Privately Operated Residential Care Facilities for the Elderly (dated 05/16/2026) Medical Assessment for Residential Care Facilities for the Elderly (dated 05/14/2026), Centrally Stored Medication and Destruction Record (dated 05/16/2026), Medication Return Form & Release of Responsibility (dated 05/28/2026), Unusual Incident/Injury Report (dated 05/29/2026, 06/02/2026, 06/05/2026, 06/10/2026, 06/16/2026 and 06/17/2026), Notification Letters from the Facility

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026

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

Control Number 11-AS-20260615182651

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: FRANCESCA'S HOME	FACILITY NUMBER: 198602216
	VISIT DATE: 08/18/2026

NARRATIVE

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(dated 06/02/2026, 06/11/2026, 06/12/2026, and 06/16/2026), Presbyterian Intercommunity Hospital Discharge Orders (dated 05/06/2026), Presbyterian Intercommunity Hospital Document Review Report (dated 05/16/2026), Presbyterian Intercommunity Hospital Adult Discharge Instructions (dated 05/04/2026) Staff Notes from 05/18/2026 to 06/22/2026, and Weekly Menu.
The investigation revealed the following:

Allegation: Staff did not administer medication as prescribed

The allegation alleges that a resident stated they need the brand name of a medication and the pharmacy provided the generic brand, resulting in the resident not getting the medication they requested.

During the facility inspection, LPA observed Staff S2 providing medications to residents. LPA observed S2 reviewed the Physician’s Orders, the Medication Administration Record (MAR), and the prescription label to ensure medications are provided as prescribed. LPA conducted a medication review for Resident’s R2-R6. LPA observed five (5) out of five (5) residents Centrally Stored Medications are consistent with their Physician’s Orders.

During record review, LPA received and reviewed Resident R1’s Admission Agreement, signed and dated 05/16/2026, that lists under Basic Services: page 3 number 16) Assistance with taking prescribed and over-the-counter medications in accordance with physician’s instructions unless prohibited by law or regulations. LPA received and reviewed the Program Description: Residential Care Facility for the Elderly, signed and dated 05/16/2026, that states “ medications will be issued according to the physician’s instructions and the instructions on the label. If there are changes to the dispensing, the facility will obtain these changes in writing from the client’s physician.” LPA received and reviewed Medication Procedures, signed and dated 05/16/2026, that states in number 9. “The Administrator shall follow the doctor’s prescriptions strictly as prescribed by the doctor’s written prescription in dispensing medications to residents.” LPA additionally received and reviewed Discharge Orders from Presbyterian Intercommunity Hospital – PIH Health, dated 05/16/2026, that indicates R1 was to start a new prescription of Dilantin 100mg oral capsule, extended release 1 cap orally 3 times a day and to discontinue Dilantin 100mg oral capsule, 1 cap orally 3 times a day. LPA observed the medication that was delivered to the facility on 06/10/2026, is labeled Dilantin 100mg Capsule, which was discontinued on 05/16/2026. Additionally, LPA received and reviewed an Unusual Incident/Injury Report dated 06/16/2026, stating the police were at the facility due to medication being withheld by staff. Police were informed by Staff S1 that they do not have an order from the Physician indicating a change in medications. Police Officers were provided documentation to verify the information and left without incident. No Report was indicated on the City of Torrance Police Department card left with an

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 11-AS-20260615182651

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: FRANCESCA'S HOME	FACILITY NUMBER: 198602216
	VISIT DATE: 08/18/2026

NARRATIVE

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incident number of 260023565.
During interviews with Staff S1-S3, were asked how they ensure residents are provided with their medications as prescribed, three (3) out of three (3) stated they follow the Physician’s Orders and the prescription label.
Durning interviews with Residents R2-R6, were asked if they receive their medications as prescribed, five (5) out of five (5) stated yes, they receive their medications as prescribed.
During interviews with Witnesses W1 and W2, were asked if their resident receives their medications as prescribed, two (2) out of two (2) stated yes, their resident receives their medications as prescribed.

During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Staff withheld meals from a resident as a form of retaliation

The allegation alleges that staff are not providing a resident with meals due to staff retaliation.

During the facility inspection, LPA inspected the food supply and observed the facility has a 3-day supply of perishable foods and a 7-day supply of nonperishable foods properly packaged, labeled, and dated. Upon entering the facility, LPA observed residents finishing breakfast. At 10am, LPA observed residents were offered a snack. At 11:30am, LPA observed staff preparing lunch and serving the residents’ lunch at 12pm.

During record review, LPA received and reviewed Resident R1’s Admission Agreement, signed and dated 05/16/2026, that lists on page 2, under Basic Services include Food Services, consisting of: 1. Three nutritious meals daily and snacks, and 2. Special diets as prescribed by a doctor. In the Program Description: Residential Care Facility for the Elderly, signed and dated 05/16/2026, LPA observed it states, The basic services include: Three (3) nutritious meals daily and between meals, nourishments and snacks. Modified diet available, if required. LPA received and reviewed Staff Notes that indicate Resident R1 refused meals the following date and times: on 05/18/2026 refused breakfast, 05/19/2026 refused breakfast and dinner, 05/20/2026 refused breakfast and dinner, 05/23/2026 refused snacks, lunch, and dinner, 05/24/2026 refused breakfast, 05/26/2026 refused dinner, 05/28/2026 refused dinner, 06/01/2026 refused lunch, 06/02/2026 refused breakfast, 06/03/2026 refused lunch, 06/04/2026 refused breakfast, dinner, and snacks, 06/05/2026 refused breakfast, lunch, and dinner, 06/07/2026 refused dinner, 06/08/2026 refused breakfast, 06/09/2026 refused breakfast and snack, 06/10/2026 refused breakfast, 06/11/2026 refused breakfast and lunch, 06/12/2026 refused breakfast, lunch, and dinner, 06/13/2026 refused breakfast, lunch, and dinner, and 06/15/2026 refused dinner. LPA observed on occasion R1 requested an alternative such as tuna,

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 11-AS-20260615182651

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: FRANCESCA'S HOME	FACILITY NUMBER: 198602216
	VISIT DATE: 08/18/2026

NARRATIVE

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spaghetti, or ravioli and would have food delivered.
During interviews with Staff S1-S3, were asked if a resident’s meals were withheld at any time, three (3) out of three (3) stated no, no meals have been withheld from a resident.
During interviews with Residents R2 -R6, were asked if there was a time they were not provided with a meal or snacks, five (5) out of five (5) stated no, they have always received their meals.
During interviews with Witnesses W1 and W2, were asked if there was a time their resident was not provided with a meal, two (2) out of two (2) stated no, not to their knowledge.

Allegation: Staff do not ensure that residents are provided a comfortable accommodations.

The allegation alleges the hospital bed the resident was provided with is broken.

During the facility inspection, LPA observed Resident R1’s room was furnished with a bed, dresser, nightstand with a lamp, chair, and storage space for resident’s belongings. LPA observed that the mattress and box spring are maintained in good condition.

During record review, LPA received and reviewed Presbyterian Intercommunity Hospital Discharge Order dated 05/06/2026 and observed a hospital bed was ordered as DME equipment and delivered by Apria. LPA observed in the Staff Notes on 06/03/2026 Resident R1 complained to the doctor that the bed is broken. The bed was checked by the doctor and staff, and it was “working perfectly fine.” Additionally, LPA observed in the Staff Notes on 06/11/2026 the Licensee received a call from the home health risk management stating Resident R1 called and reported their bed was broken. The bed was checked and the Licensee informed them the bed was not broken. LPA received and reviewed Resident R1’s Admission Agreement and Program Description: Residential Care Facility for the Elderly, signed and dated 05/16/2026, on page 1, under Basic Services, that states a “Comfortable and suitable bed and bedroom furniture.”
During interviews with Staff S1-S3, were asked how they ensure residents are provided with comfortable accommodations, three (3) out of three (3) stated they ensure the rooms are clean and have the furniture the residents require.
During interviews with Residents R2 -R6, were asked if they are provided with comfortable accommodations, five (5) out of five (5) stated yes, they are provided with comfortable accommodations.
During interviews with Witnesses W1 and W2, were asked if their resident is provided with comfortable

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 11-AS-20260615182651

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: FRANCESCA'S HOME	FACILITY NUMBER: 198602216
	VISIT DATE: 08/18/2026

NARRATIVE

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accommodations, two (2) out of two (2) stated yes, their resident is provided with comfortable accommodations.

Allegation: Staff do not treat residents with dignity and respect

The allegation alleges staff brought their dog to the facility when asked not to, retaliated against resident for calling the police, and was not given the password for the television.

During the facility inspection, LPA observed interactions between staff and residents. LPA observed the staff speaking respectfully to residents and while providing care staff provided them with privacy.

During record review, LPA observed LPA received and reviewed Resident R1’s Personal Rights of Residents in Privately Operated Residential care Facilities for the Elderly, signed and dated 05/16/2026, that states on page 2 residents have the right “to be accorded dignity in their personal relationships with staff, residents, and other persons,” and the right to “ to have reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.” LPA received and reviewed Staff Notes for Resident R1 that indicates on 06/10/2026 and 06/15/2026, R1 was provided with the Wi-Fi password.
During interviews with Staff S1-S3, were asked how they ensure residents are treated with dignity and respect, three (3) out of three (3) stated they listen to their wants and needs, and provide privacy when assisting residents, or when they have a visitor or are on the phone.
During interviews with Residents R2 -R6, were asked if staff treat them with respect and dignity, five (5) out of five (5) stated yes, staff treat them with respect and dignity.
During interviews with Witnesses W1 and W2, were asked if staff treat their resident with respect and dignity, two (2) out of two (2) stated yes, staff treat their resident with dignity and respect.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 11-AS-20260615182651

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: FRANCESCA'S HOME	FACILITY NUMBER: 198602216
	VISIT DATE: 08/18/2026

NARRATIVE

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Allegation: Staff not providing records to the authorized representative/resident
The allegation alleges the resident asked to be shown the medication and the staff would not show them.

During the facility inspection, LPA observed Centrally Stored Medications secured in a locked filing cabinet, in a locked staff room.

During record review, LPA received and reviewed Resident R1 Staff Notes that states on 06/14/2026, R1 requested to take a picture of their medication that they have been working on getting a refill for. A picture of the bottle was taken with R1’s cell phone. Additionally, LPA received and reviewed Resident R1’s Personal Rights of Residents in Privately Operated Residential Care Facilities for the Elderly, signed and dated 05/16/2026, that states on page 5, residents have the following personal right “to have prompt access to review all of their records and to purchase photocopies of their record. Photocopied records shall be provided within two (2) business days and at a cost that does not exceed the community standard for photocopies.”
During interviews with Staff S1-S3, were asked residents and/or responsible person is provided with requested information and/or documents, three (3) out of three (3) stated yes, they are provided right away.
During interviews with Residents R2-R6, were asked if staff provide residents and/or their authorized representative with requested records or information, five (5) out of five (5) stated yes, they receive it right away and there have been no issues.
During interviews with Witnesses W1 and W2, were asked if staff provide them with requested records or information, two (2) out of two (2) stated yes, they are provided with documents right away and provided information on any changes.

LPA did not observe or cite any deficiencies.

An exit interview was conducted with Licensee, Bessie Coello, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 08/18/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2026

LIC9099 (FAS) - (06/04)

Page: 6 of 6