198602627-4-10-2026-11-AS-JHAD-DT7NZS-20260416105448

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602627
Report Date: 04/10/2026
Date Signed: 04/10/2026 02:51:20 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, 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
01/29/2025 and conducted by Evaluator Lizeth Villegas

COMPLAINT CONTROL NUMBER: 11-AS-20250129170530

FACILITY NAME:	CALIFORNIA MENTOR - 230TH STREET HOME		FACILITY NUMBER:	198602627
ADMINISTRATOR:	ROSAS, CLAUDIO		FACILITY TYPE:	735
ADDRESS:	434 W 230TH STREET		TELEPHONE:	(909) 483-2505
CITY:	CARSON	STATE: CA	ZIP CODE:	90745
CAPACITY:	3	CENSUS: 3	DATE:	04/10/2026
		UNANNOUNCED	TIME BEGAN:	01:16 PM
MET WITH:	Administrator Nickie Southall		TIME COMPLETED:	02:27 PM

ALLEGATION(S):

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Resident sustained unexplained fracture while in care.

INVESTIGATION FINDINGS:

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On 04/10/26 The Department conducted an unannounced subsequent visit to deliver complaint findings for the allegation(s) above. The Department met with Administrator as the purpose of the visit was explained.

The investigation consisted of the following:
On 01/31/2025, The Department conducted the initial visit and obtained copies of the following documents; Staff Roster, Client Roster, Client Face Sheet, Physician’s Report (dated 02/15/2024), Functional Capability Assessment (dated 05/15/2024), Appraisal/Needs and Service Plan (dated 05/15/2024), Weekly and PRN Comprehensive Nursing Assessment (dated 01/13/2025), Health & Safety Assessment: Personal Safety Individual Interview/Assessment (dated 05/15/2024), Medical/Dental/Lab Appointment Form (dated 11/22/2024 and12/04/2024), R.O.A.D.S. Community Care Clinic summary Visit (dated 12/04/2024), Harbor-UCLA Medical Center discharge instructions (dated 11/22/2024), Communication Log (dated 10/30/2024), Quarterly Nursing Report (dated 12/03/2024 and 08/27/2024), Harbor Regional Center Individual Program Plan (IPP) (dated 05/15/2025), Individual Service Plan (dated 12/03/2024), Occupational Therapy

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2026

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 3

Control Number 11-AS-20250129170530

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: CALIFORNIA MENTOR - 230TH STREET HOME	FACILITY NUMBER: 198602627
	VISIT DATE: 04/10/2026

NARRATIVE

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Update (dated 12/2024 and 08/2024), Unusual Incident/Injury Report (dated 01/28/2025, 01/04/2025, 11/21/2024) and Staff Training Logs (dated 01/22/2025, 12/06/2024, 08/23/2024, and 08/14/2024). On 02/25/25, 03/21/25, and 04/22/25 The Department conducted interviews with staff #1-5 (S1-S5), on 02/25/25 The Department interviewed clients #1-2 (C1-C2), and on 04/22/25 and 10/21/25 The Department conducted interviews with Witness #1 (W1).

The investigation revealed the following:

Allegation: client sustained an unexplained fracture while in care.

It is alleged that C1 was found to have an unexplained fracture on knee. On 02/25/25, 03/21/25, and 04/22/25 The Department conducted interviews with S1-S5 regarding the allegation above, 5 of 5 staff interviewed denied the allegation above. 5 of 5 staff interviewed reported C1 did not experienced a fall on 11/21/24, however Per 5 of 5 staff interviewed, in November 2024 while C1 transferred from bed to shower chair C1 stubbed toe but did not fall. On 02/25/25 The Department attempted to interview C1 but was unsuccessful due to communication barrios. On 02/25/25 The Department attempted to interview C2, however C2 did not want to interview. On 04/22/25 and 10/21/25 The Department conducted an interview with Witness #1 (W1) regarding the allegation above, per W1 C1 sustained fractures on both legs prior to living at CALIFORNIA MENTOR - 230TH STREET HOME. W1 continued to report that on 01/28/25 attending Doctor at Harbor UCLA Medical Center stated that there was nothing wrong with C1’s knee, however there were some concerns as C1 was visiting the hospital too frequently for injuries.

The Department received and reviewed medical records from Harbor UCLA Medical Center (dated 01/28/2025), records indicated C1 was transferred to the Emergency Department due to swelling to the right knee. C1 had a CT scan that indicated a possible avulsion fracture with a moderate effusion. Additionally, the department received and reviewed records from Advanced Care Orthopedics (02/24/2025) that indicated C1 with an unspecified fracture of right patella. Due to diffusely decrease bone mineralization the x-rays and CT scan evaluation of a fracture was limited. The department received an Unusual Incident/Injury Report on 11/30/2025 regarding an incident that occurred on 11/21/2024 with C1. Per incident report, C1 was taken to Harbor UCLA ER for stubbing their toe while being transferred from the bed to the wheelchair. The Department additionally received and reviewed, staffing Note Summary Report from 11/04/2024 to 02/24/2025 that indicates that on 11/20/2024 C1 stubbed their right middle toe, and on 11/21/2024 C1 was uneasy and was in pain from a fall earlier in the day. It was also noted that on 01/27/2025, C1’s right knee

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20250129170530

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: CALIFORNIA MENTOR - 230TH STREET HOME	FACILITY NUMBER: 198602627
	VISIT DATE: 04/10/2026

NARRATIVE

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was swollen, ice was applied and LVN was notified. On 01/28/2025, a note indicates C1’s right knee was super swollen, and left toe was bruised, C1 was then transported to the Emergency Room where they were diagnosed with an unspecified fracture of the right patella. The department conducted review of C1’s Individual Service Plan (ISP), per ISP C1 will be provided 24-hour supervision by home staff, and C1 will not have unsupervised time hours. The Department conducted an additional review of records obtained, based on The Departments review the review of recurring swelling of C1’s right knee and orthopedic note of Unspecified fracture of right patella, sequela, C1’s right knee swelling is long term residual effects from C1’s initial injury. It has been concluded that C1’s fracture was not due to caregiver’s lack of 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.

Exit interview conducted, and a copy of this report was provided to thee Administrator.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Lizeth Villegas
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2026

LIC9099 (FAS) - (06/04)

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