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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603504
Report Date: 07/14/2026
Date Signed: 07/14/2026 11:27:42 AM

Unsubstantiated


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
02/08/2026 and conducted by Evaluator Daniel Konishi
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20260208231203
FACILITY NAME:LA POSADAFACILITY NUMBER:
198603504
ADMINISTRATOR:BEATRIZ ROMEO-LUIFACILITY TYPE:
740
ADDRESS:8120 PAINTER AVETELEPHONE:
(562) 945-2651
CITY:WHITTIERSTATE: CAZIP CODE:
90602
CAPACITY:114CENSUS: 85DATE:
07/14/2026
UNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Colleen Rozatti, Executive DirectorTIME COMPLETED:
11:35 AM
ALLEGATION(S):
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Staff neglect resulted in resident deaths
Staff are not properly trained
Staff mishandle the residents medications
Staff member consumes alcohol during work hours, impairing their ability to provide adequate care and supervision, which presents a risk to residents in care
Staff are not addressing a resident's change in medical condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Daniel Konishi conducted a subsequent unannounced complaint visit in response to the above-mentioned allegations. LPA met with the Executive Director, Colleen Rozatti, and explained the reason for the visit.

On 2/10/2026, the initial investigation visit was conducted. The investigation consisted of the following:

LPA requested a copy of staff and resident rosters. LPA conducted a tour of facility and common areas with the Office Manager. LPA also requested copies of staff and resident rosters. LPA obtained death reports from November 2025 to February 2026. LPA reviewed and obtained documents from Staff #1 (S1’s) file such as job description duties, employment application, and other pertinent documents. LPA observed the residents to identify any signs of neglect, abuse, or other immediate health and safety threats. LPA did not observe any immediate health and/or safety concerns.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026
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 5
Control Number 28-AS-20260208231203
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: LA POSADA
FACILITY NUMBER: 198603504
VISIT DATE: 07/14/2026
NARRATIVE
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However, one (1) out nine (9) residents denied the allegation stating that wound care treatment is provided by home health specialist. LPA observed during the visit that a home health care specialist visit to help conduct wound care for one (1) resident. LPA also reviewed records of a document of a home health visit for wound care treatment. There is not enough evidence to substantiate.

Based on statements and interviews conducted with staff, residents, review of resident files and facility file records, there was not enough supportive evidence to concur with the reported allegation. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview was held, and a copy of this report was provided to the Executive Director, Colleen Rozatti.
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 28-AS-20260208231203
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: LA POSADA
FACILITY NUMBER: 198603504
VISIT DATE: 07/14/2026
NARRATIVE
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On 3/05/2026, the initial investigation visit was conducted. The investigation consisted of the following:

LPA Konishi obtained the following documents: staff and resident rosters. LPA interviewed the Former Executive Director, Staff #1 (S1) to Staff #7 (S7), and Resident #1 (R1) to Resident #9 (R9). LPA reviewed a random sample of nine (9) residents’ medications. LPA obtained Death Reports, Outside Agency/Services Documentation, Resident Charting Notes, and other pertinent documents.

On 3/20/2026, LPA interviewed Staff #8 (S8) over the phone.

On 03/23/2026, LPA interviewed Staff #9 (S9) over the phone.



On 03/25/2026, LPA interviewed Staff #10 (S10) over the phone.

On 5/15/2026, LPA interviewed Staff #9 (S9) over the phone.

On 5/27/2026, LPA requested documentation from Staff #2 (S2). S2 sent documentation to the LPA by email on 5/27/2026.

During today's visit, the investigation consisted of the following: LPA obtained staff and resident rosters, and other pertinent documents.



The investigation revealed the following: in regard to the allegation, “Staff neglect resulted in resident deaths.” It is alleged that the facility has had three (3) recent deaths due to staff neglect and not being sure how to handle situations. LPA was only provided the details of and name of one (1) of the three (3) residents that were deceased in the past three months which per death report, Former Resident #1 (FR1) passed on 02/08/2026 and cause of death was listed as respiratory decline. No information was provided regarding the identities of the other two (2) alleged residents that passed away due to staff neglect. LPA interviewed the Former Executive Director, and an additional nine (9) staff that denied the allegation stating that the three (3) recent deaths were not questionable stating that residents passed due to decline in health, being under hospice care, and not under unusual causes. LPA reviewed recent death reports from the facility. LPA reviewed five recent death reports in which cause of death were due to natural causes or under hospice care. LPA could not find any death reports that had causes that were questionable. Former Resident #2 (FR2) passed away on 01/09/2026 and cardiac arrest and Alzheimer’s Dementia were the cause of death. [Continue to LIC9099-C]
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20260208231203
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: LA POSADA
FACILITY NUMBER: 198603504
VISIT DATE: 07/14/2026
NARRATIVE
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 LPA interviewed one (1) out of ten (10) staff that corroborated with the allegation stating that they were being told that the staff were pre-pour syringes and pop medication from other residents medication packs. However, that one (1) staff was not direct a witness to this. LPA interviewed eight (8) out of nine (9) residents that denied the allegation stating that staff does not mishandle medications and medications are given as prescribed. LPA interviewed one (1) out of nine (9) residents that corroborated with the allegation stating being given the wrong medication by staff but this occurred four (4) years ago. LPA reviewed a random sample of medications of nine (9) residents and all medications are given as prescribed. There is not enough evidence to substantiate.

Allegation: “Staff member consumes alcohol during work hours, impairing their ability to provide adequate care and supervision, which presents a risk to residents in care.” It is alleged that S1 drank alcohol while on duty. LPA interviewed one (1) out of ten (10) staff that corroborated with the allegation stating on witnessing Staff #1 (S1) an alcoholic drink on duty at the facility and also stated that Staff #2 (S2) gave this drink to S1. However, that one (1) out of ten (10) staff was unable to provide any evidence. LPA interviewed S1 that denied the allegation stating not drinking alcohol while on duty and was not given the alcohol drink from S2 or any staff. LPA interviewed S2 that also denied the allegation stating not drinking alcohol while on duty and did not hand any alcoholic drink to S1 or any other staff. LPA interviewed the Former Executive Director and seven (7) additional staff that denied the allegation stating not witnessing S1 drinking alcohol while on duty. Per licensee, there was no investigation nor employee suspension since there was no credible evidence provided. LPA interviewed nine (9) out of nine (9) residents that denied the allegation stating not witnessing S1 or any staff drinking alcohol while on duty. There is not enough evidence to substantiate.

Allegation: “Staff are not addressing a resident's change in medical condition.” It is alleged that the facility staff LVN (Licensed Vocational Nurse) that refuses to do wound care. LPA interviewed the Former Executive Director, and nine (9) out of ten (10) staff that denied the allegation stating that the LVN staff does not refuse to do wound care but wound care is done by a licensed medical professional nurse, hospice care specialist, or home health care specialist. One (1) out of ten (10) staff stated not sure who handled wound care treatment but stated that the caregivers of the facility does not treat wound care. LPA interviewed nine (9) out of nine (9) resident that stated they do not need nor require wound care treatment. [Continue to LIC9099-C]
SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20260208231203
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: LA POSADA
FACILITY NUMBER: 198603504
VISIT DATE: 07/14/2026
NARRATIVE
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Former Resident #3 (FR3) passed away on 01/30/2026 and acute cardiopulmonary arrest was the cause of death. Former Resident #4 (FR4) passed away on 01/30/2026 and end stage renal failure was the cause of death. Former Resident #5 (FR5) passed away on 03/10/2026 and cardiac arrest was the cause of death. Per review of documentation the reported deaths don’t seem suspicious as all three (3) deaths seemed to be of natural causes. LPA interviewed nine (9) out of nine (9) residents that could not confirm or deny the allegation stating that they don’t know of any questionable deaths due to staff neglect. There is not enough evidence to substantiate.

Allegation: ”Staff are not properly trained.” It is alleged that the facility has a med tech without any med tech certification. LPA interviewed the Former Executive Director, nine (9) out of ten (10) denied the allegation stating that all med techs have med tech certification and on-going staff training completed. One (1) out of ten (10) staff was not sure about med tech certification as they are a caregiver and not a med tech but stated that medications are provided from staff to residents as prescribed. LPA reviewed documentation of five (5) med techs file that included valid med tech certification and ongoing staff training completed such as the following topics: California Prohibited and Restricted Conditions, Assisted with Self Administration of Medications, Dementia 101, An Overview of Quality Dementia Care, Alzheimer’s Disease and Related Disorders: ADL Care, Alzheimer’s Disease and Related Disorders: The Environment, Dementia Care: Normal Aging vs. Alzheimer’s/Dementia, Dementia Care: Activities for People with Memory Problems, and Abuse: Preventing, Recognizing, and Reporting. LPA interviewed nine (9) out of nine (9) residents that stated that the staff properly provide care and services and not neglect care. There is not enough evidence to substantiate.

Allegation: “Staff mishandle the residents medications.” It is alleged that the facility staff administer morphine to a patient without a nurse present. It is also alleged that the facility staff puncture a resident with pre-filled syringes and they also pop medications from other residents medication packs. LPA interviewed the Former Executive Director, and six (6) out of ten (10) staff that denied the allegation stating that morphine is properly administered to the residents at the facility and that liquid morphine is provided by a licensed medical professional. The Former Executive Director, and six (6) out of ten (10) staff also stated that the staff does not pre-pour syringes and do not pop medications from other residents medication packs. LPA interviewed three (3) out of ten (10) staff who stated that they are not involved with handling medication administration so they were unable to provide an answer regarding this allegation. [Continue to LIC9099-C]

SUPERVISORS NAME: David Sicairos
LICENSING EVALUATOR NAME: Daniel Konishi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5