198603504-8-13-2026-28-AS-LHIS-DXHW3X-20260901165640

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603504
Report Date: 08/13/2026
Date Signed: 08/13/2026 02:38:06 PM

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
07/13/2026 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20260713153031

FACILITY NAME:	LA POSADA		FACILITY NUMBER:	198603504
ADMINISTRATOR:	COLLEEN ROZATTI		FACILITY TYPE:	740
ADDRESS:	8120 PAINTER AVE		TELEPHONE:	(562) 945-2651
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90602
CAPACITY:	114	CENSUS: 86	DATE:	08/13/2026
		UNANNOUNCED	TIME BEGAN:	08:57 AM
MET WITH:	Colleen Rozatti, Executive Director		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Staff neglect resulted in resident’s death.
Staff did not report a change in condition to resident’s representative.
Staff did not follow isolation procedures for illness.
Facility did not provide records to resident’s representative.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint investigation visit regarding the above allegations. The purpose of the visit was explained to Executive Director Colleen Rozatti.

The investigation consisted of the following: On 7/15/2026, record review was completed, resident (R1's) file documents and infection control plan were obtained, and staff (S1-S4) were interviewed. During today's visit, the physical plant was toured, additional record review was completed and staff (S5-S7) and residents (R2- R9) were interviewed.

Report continuation- see LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20260713153031

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: 08/13/2026

NARRATIVE

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Allegation: Staff did not follow isolation procedures for illness. It is alleged that the Memory Care Unit did not have infection control isolation procedures in place because on January 31, 2026, during a visit no staff or residents were observed wearing masks, and no PPE containers were observed in the unit. According to information obtained, only a suction canister was observed inside deceased resident (R1's) room. Based on interviews conducted, the findings indicate that once Memory Care Unit staff learned that R1's roommate had RSV, infection control practices were put in place. R1's roommate was isolated in a different room, and when R1 returned from the hospital the resident was isolated by themselves in their room. Records indicate that R1's roommate returned to the facility on 1/7/2026, and was isolated and quarantined for 5 days. Per interviews, doctors determine the number of isolation days, and if the facility is unable to accommodate the resident(s) the hospital transfers residents to a skilled nursing facility. Staff denied the allegation and stated they follow orders. There is insufficient supporting information to confirm the allegation.

Allegation: Facility did not provide records to resident’s representative. It is alleged that on March 12, 2026, resident (R1's) representatives met with Resident Care Coordinator, new Wellness Director, and hospice nurse to discuss the reason R1's was sent out to the emergency room on January 26, 2026 despite being enrolled in hospice care. The complaint alleges that R1's representative was informed that R1 and their roommate were not fully isolated due to capacity constraints. According to information obtained, R1's records were requested on March 9, 2026 and no response was received. Based on staff interviews, a meeting was held because R1's representative requested documents. Staff stated that the resident's Medical Assessment, hospice documents, and medication list was provided to the representative. According to staff, facility provides a summary email to representatives regarding incident report details, but no internal documents. Administration staff stated families/authorized representatives have access to resident file documents via August Health electronic health records, and are able to print the documents. The facility requires all document requests be emailed, unless it is a request from a law firm. There is insufficient evidence to support the allegation.

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

An exit interview was conducted with Executive Director Colleen Rozatti. A copy of the report was issued.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20260713153031

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: 08/13/2026

NARRATIVE

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Allegation: Staff neglect resulted in resident’s death. The complaint alleges that on January 26, 2026 resident (R1) was sent to the emergency room with a fever and unresponsive, but earlier that day the resident was alert, communicative, and in stable health. A total of 7 staff were interviewed. Six out of seven staff denied the allegation. Staff interviews revealed that resident (R1's) roommate had Respiratory Syncytial Virus (RSV) without symptoms, but changes to their baseline were noted. According to staff interviews, a few days later resident (R1) began displaying changes to their baseline and was sent out to the hospital for an evaluation because a change in condition was noted. Record review was completed. The findings indicate resident (R1) was enrolled in hospice at the time of death. According to facility records, on January 12, 2026, care staff noted changes in R1 i.e., lethargy and change in appetite. Resident (R1's) roommate was diagnosed with RSV on January 2,/2026, and returned to the facility on January 7, 2026. Upon return R1's roommate was isolated in a different room and quarantined for 5 days. Resident (R1) was sent out to the hospital on January 26, 2026 at approximately 11:56 PM and returned to the facility on January 27, 2026 at approximately 2:40 AM with oxygen. Hospice was notified. Resident (R1) showed signs of decline. Care staff notified hospice accordingly. On January 29, 2026, hospice sent out a bed side nurse for the night. Resident (R1) passed away on January 30, 2026 at 6:15 AM. The Death Certificate lists the cause of death as acute cardiopulmonary arrest and Senile Dementia. There is insufficient evidence to support the allegation.

Allegation: Staff did not report a change in condition to resident’s representative. It is alleged facility staff did not communicate or was honest with the resident's representative that resident (R1) was experiencing changes and decline, until before transporting R1 to the hospital because the resident had a fever. It is also alleged that facility staff did not inform R1's representative that the resident was exposed to RSV. Based on staff interviews, former Executive Director did not immediately notify Memory Care Unit staff that R1's roommate had confirmed RSV. According to staff, once they received information, they started isolating resident (R1). Staff stated that resident's responsible parties are immediately notified of any change in condition. Records indicate that R1's representative was contacted telephonically by facility staff whenever there was a change in condition. Residents interviewed did not agree with the allegation. They stated that staff promptly notify their responsible parties when there are changes in condition. The findings indicate their is insufficient information to support the allegation.

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:	DATE: 08/13/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2026

LIC9099 (FAS) - (06/04)

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