197608888-4-22-2026-11-AS-SCIS-DUUW3Q-20260608165617

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608888
Report Date: 04/22/2026
Date Signed: 04/22/2026 12:11:10 PM

Substantiated

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
10/02/2025 and conducted by Evaluator Elvira Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20251002104817

FACILITY NAME:	WEST PICO TERRACE ASSISTED LIVING CENTER LP		FACILITY NUMBER:	197608888
ADMINISTRATOR:	CHRISTOPHER,MELISSA		FACILITY TYPE:	740
ADDRESS:	6050 W PICO BLVD		TELEPHONE:	(323) 653-5565
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90035
CAPACITY:	136	CENSUS: 90	DATE:	04/22/2026
		UNANNOUNCED	TIME BEGAN:	10:14 AM
MET WITH:	Azucena Reyes		TIME COMPLETED:	12:20 PM

ALLEGATION(S):

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Facility staff are not properly supervising resident who is a fall risk.

INVESTIGATION FINDINGS:

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** This report serves as an amendment to amend findings. This report supersedes the complaint investigation findings reflected on report created 03/16/26. ** On 04/22/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced subsequent complaint investigation visit for the allegation listed above. LPA met with Administrator, Azucena Reyes, and explained the purpose of this visit is to provide an amended copy of the LIC9099 report.

On 02/10/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint investigation visit to investigate the above-mentioned allegation and deliver findings. LPA met with Administrator Azucena Reyes, explained the purpose of the visit, and was granted entry into the facility.

Continued on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026

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 4

Control Number 11-AS-20251002104817

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: WEST PICO TERRACE ASSISTED LIVING CENTER LP	FACILITY NUMBER: 197608888
	VISIT DATE: 04/22/2026

NARRATIVE

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The investigation consisted of the following: On 10/08/25, LPA Gonzalez requested and obtained the staff roster and resident roster. LPA Gonzalez reviewed service records for resident #1 (R1) and requested copies of the following documents: Admission Record, Physician’s Report, Service Plan Report, Unusual Incident/Injury Reports, Medication Administration Record (MAR) for September 2025, Senior Living Assessment, medical records from Cedars-Sinai, and the In-Service/Staff Meeting Training Log. LPA Gonzalez conducted interviews with staff #1–#4 (S1–S4) and residents #2–#8 (R2–R8) and attempted to interview R1. On 01/06/26, LPA Gonzalez received additional documentation from Administrator Azucena Reyes, including the Service Plan Report and medical records from East Los Angeles Doctors Hospital for R1 (dated 10/08/25). On 02/10/26, LPA Gonzalez attempted to conduct an interview with R1. Additionally, LPA Gonzalez obtained a copy of R1’s Death Report.

The investigation revealed the following:

For the allegation: Facility staff are not properly supervising a resident who is a fall risk. It is alleged that the resident experienced multiple unwitnessed falls, resulting in injuries. On 10/08/25, LPA Gonzalez interviewed S1–S4. Of those interviewed, 4 out of 4 staff denied the allegation. 4 out of 4 staff said they have been trained in fall risk management. All staff stated that R1 does not have a one-on-one caregiver assigned, and that residents are checked every 2–3 hours and as needed. During the interview, S1 stated that R1 has resided at the facility for an extended period of time and is familiar with the layout of the facility. S1 reported that R1 frequently wanders throughout the facility and the adjacent Skilled Nursing Facility (SNF). S1 stated that caregivers are available 24 hours a day, 7 days a week, but no residents at the facility are assigned a one-on-one caregiver.

On 10/08/25, LPA Gonzalez conducted interviews with residents R2–R8. On 02/10/26, LPA Gonzalez attempted to conduct an interview with resident R1 but was unable to as LPA was informed that R1 had passed away on 10/31/26. Of those interviewed, 7 out of 7 residents stated that staff check on them frequently. 7 out of 7 residents stated that staff provide the necessary care and supervision required.
On 10/08/25, LPA Gonzalez conducted a review of records. Records reviewed included R1’s Physician’s Report dated 05/23/25, which documents that R1 is non-ambulatory, uses a wheelchair, and is unable to leave the facility unassisted.

Continued on LIC9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20251002104817

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: WEST PICO TERRACE ASSISTED LIVING CENTER LP	FACILITY NUMBER: 197608888
	VISIT DATE: 04/22/2026

NARRATIVE

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A review of R1’s Service Plan Report dated 07/12/24 indicates that R1 is not to be left unattended in the community, and staff are required to monitor R1’s whereabouts every two to three hours due to wandering behaviors. The LPA also observed a Fall Care Plan within R1’s Service Plan that outlines fall prevention interventions, including the use of bed rails, frequent rounds every two to three hours, access to a call light, ensuring a caregiver is within reach, and providing cueing and gentle reminders. Additionally, under the Mobility section of the Service Plan Report, it states that R1 is chairfast, utilizes a wheelchair for mobility, and is able to move about the community with assistance. A review of an Unusual Incident/Injury Report dated 09/17/25 documents that R1 sustained an unwitnessed fall on 09/17/25. The report indicates that 911 was called and R1 was transported to Cedars-Sinai Hospital. A review of an Unusual Incident/Injury Report dated 10/01/25 documents that R1 sustained an unwitnessed fall on 09/29/25. According to the report, paramedics did not respond on 09/30/25. On 10/01/25, R1 was transported to East Los Angeles Hospital. A review of medical records from East Los Angeles Hospital dated 10/08/25 documents that R1 was admitted on 10/01/25 for generalized weakness and an unwitnessed fall. The records further indicate that R1 was discharged on 10/08/25 with orders to continue medications, monitoring, and placement in a skilled nursing facility (SNF). On 02/10/26, LPA Gonzalez conducted a review of R1’s Death Report dated 11/07/25, which indicates that R1 passed away on 10/31/25.

Based on records reviewed, and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title 22, Division 6 is being cited on the attached LIC9099-D.

An exit interview was conducted, and a copy of the report, along with appeal rights was provided to Azucena Reyes.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 11-AS-20251002104817

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: WEST PICO TERRACE ASSISTED LIVING CENTER LP	FACILITY NUMBER: 197608888
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/22/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/29/2026 Section Cited CCR 87468.1	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all...(2) To be accorded safe, healthful and comfortable accommodations... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Licensee/Administrator shall ensure that all staff are trained on fall prevention and resident-specific care plans. Documentation of staff training will be submitted to the Department by 04/29/26 to Elvira.Gonzalez@DSS.CA.GOV
	8 9 10 11 12 13 14	Based on records reviewed, and interviews conducted, the Licensee failed to adequately supervise (R1) on 09/17/25, and 09/29/25, resulting in unwitnessed falls and sustaining injuries. This violation poses an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 04/22/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/22/2026

LIC9099 (FAS) - (06/04)

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