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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603504
Report Date: 07/31/2025
Date Signed: 07/31/2025 09:41:33 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/22/2025 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250122154956
FACILITY NAME:LA POSADAFACILITY NUMBER:
198603504
ADMINISTRATOR:DIANA BAUTISTAFACILITY TYPE:
740
ADDRESS:8120 PAINTER AVETELEPHONE:
(562) 945-2651
CITY:WHITTIERSTATE: CAZIP CODE:
90602
CAPACITY:114CENSUS: 77DATE:
07/31/2025
UNANNOUNCEDTIME BEGAN:
09:16 AM
MET WITH:Breanna Randolph, Resident Care CoordinatorTIME COMPLETED:
09:45 AM
ALLEGATION(S):
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Staff are not repositioning resident every 2 hours.
Resident received an unexplained injury.
INVESTIGATION FINDINGS:
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**This report supersedes the report issued on 5/2/2025. The purpose is to provide a corrected finding on the above allegations. Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint investigation visit regarding the above allegations. LPA discussed the purpose of the visit was explained to Resident Care Coordinator Breanna Randolph. Executive Director Beatriz Romeo-Lui was not available.

The investigation consisted of: On 1/31/2025, a physical plant tour of the interior common areas, record review, and staff interviews with (S1- S7) was completed. Resident (R1) passed away on 1/29/2025 and was not interviewed. Resident (R1's) files documents [Face Sheet, Hospice Care Plan, Charting Notes, Skin Integrity Monitoring Form, LIC 500 Personnel Report, and resident roster were obtained. During today's visit, LPA toured the physical plant, with special focus on bedridden resident rooms. Residents (R2- R6) were observed and interviewed.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
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 2
Control Number 28-AS-20250122154956
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: LA POSADA
FACILITY NUMBER: 198603504
VISIT DATE: 07/31/2025
NARRATIVE
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Allegation: Staff are not repositioning resident every 2 hours. It was reported that hospice resident (R1) required repositioning every 2 hours due to a sacral pressure injury, but despite regular hospice wound care the pressure injury was getting worse. Seven (7) staff were interviewed. Caregiver staff stated they checked on the resident every 2 hours, and as the resident's health declined staff were checking on the resident at least every hour. Staff stated sometimes R1 refused to be repositioned every 2 hours because the resident preferred to lay in bed in a flat position due to pain when rotated to the side. Staff acknowledged that sometimes the NOC shift caregiver staff did not log in routine checks. It is unknown if they performed rotations on the resident. One of the NOC shift staff (S8) in question was terminated on January 24, 2025 for misconduct and suspicions of improper handling of cognitively impaired residents during incontinence changes. Bedridden residents were interviewed. One (1) resident stated staff are not repositioning every 2 hours, especially during night time. Charting notes [1/1/25 - 1/29/25], records indicate that the majority of the time R1 was routinely being checked every 2 hours. Record review revealed that on several dates staff checked the resident past the required repositioning time, and many of the documented checks did not specify whether the resident was repositioned every 2 hours. However, staff interviews revealed that R1 at times preferred not to be repositioned.

Allegation: Resident received an unexplained injury. On January 17, 2025, AM shift caregiver staff observed a bruise under resident (R1's) right eye. The injury was documented on a Skin Integrity Monitoring Form and med-tech staff were notified. None of the residents interviewed reported staff rough handling incidents that have caused bruising. All seven (7) staff interviewed confirmed that resident (R1) had a bruise under the right eye. Staff interviews revealed that former NOC shift staff (S8) stated that when the resident was being turned the resident's hand hit their own face. Staff stated that R1 was experiencing agitation behaviors during repositioning assistance, and may have unintentionally hit themselves. The majority of staff interviewed do not believe the bruise was intentionally caused by malicious intent, but confirmed the resident sustained an unexplained bruise. Picture evidence of the injury was obtained.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

An exit interview was conducted and a copy of this report was discussed and provided to Resident Care Coordinator Breanna Randolph.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Noemi Galarza
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2