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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608888
Report Date: 06/03/2026
Date Signed: 06/03/2026 01:44:31 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 LPFACILITY NUMBER:
197608888
ADMINISTRATOR:CHRISTOPHER,MELISSAFACILITY TYPE:
740
ADDRESS:6050 W PICO BLVDTELEPHONE:
(323) 653-5565
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:136CENSUS: 92DATE:
06/03/2026
UNANNOUNCEDTIME BEGAN:
08:34 AM
MET WITH:Azucena ReyesTIME COMPLETED:
01:45 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 clarify findings. It does not supersede the complaint investigation findings reflected on report created 04/22/26. *

On 06/03/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint visit to deliver an amended report. LPA met with Administrator, Azucena Reyes, and explained the purpose of this visit is to provide an amended copy of the LIC9099 report.

On 04/22/26, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint investigation visit to deliver findings on the above-mentioned allegation. 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: 06/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2026
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 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: 06/03/2026
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 (dated 09/17/26), 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 R1's Service Plan Report and medical records from East Los Angeles Doctors Hospital (dated 10/08/25). On 02/10/26, LPA Gonzalez attempted to conduct an interview with R1, and obtained a copy of R1’s Death Report. On 06/03/26, LPA Gonzalez conducted a second interview with S2.

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. 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 resident at the facility are assigned a one-on-one caregiver. S1 reported that R1 was at the SNF for one of the two mentioned falls, and that the SNF charge nurse saw R1 when they fell, and alerted staff about the fall and called 911.

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 10/31/25. 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.



CONTINUED ON LIC9099-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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: 06/03/2026
NARRATIVE
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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. 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. 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. Additionally, under the Elopement Risk section of the Service Plan Report, it states that R1 is not to leave the community unattended, and that staff will monitor R1’s whereabouts throughout the facility every 2-3 hours or more. 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 medical records from Cedars Sinai dated 09/17/25 documents that R1 was seen due to a fall, and head injury. Records indicate that R1 was diagnosed with a closed head injury, initial encounter, laceration of scalp, initial encounter, and a fall, initial encounter, and was instructed to follow-up with their primary doctor to have the wound rechecked and sutures removed in 7 days. A review of an Unusual Incident/Injury Report dated 10/01/25 documented that R1 sustained an unwitnessed fall on 09/29/25. According to the report, emergency medical services did not respond on 09/30/25. The Incident Report further indicated that R1 was transported to East Los Angeles Hospital on 10/01/25. An interview with S2 conducted on 06/03/26, revealed that R1 sustained an unwitnessed fall on 09/29/25 between approximately 08:00 p.m. and 09:00 p.m. S2 stated that on 09/30/25, upon R1’s return from a dialysis appointment, staff decided to contact emergency medical services and have R1 transported to the hospital for further evaluation; however, emergency personnel did not arrive to transport R1. S2 further stated that on 10/01/25, S1 made a complaint regarding emergency services’ failure to respond, after which emergency personnel arrived and transported R1 to East Los Angeles Hospital for evaluation.



CONTINUED ON LIC9099-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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: 06/03/2026
NARRATIVE
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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. Records indicate that R1 has a previous fall three weeks prior which resulted in a laceration to the top of their head for which they were taken to Cedar-Sinai Medical Center and the laceration was repaired. 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) to continue physical therapy treatments, including balance training, basic training, basic activities of daily living, equipment training, gait training, neuromuscular re-education, patient education, posture/body mechanics training, stair training, therapeutic exercise, and transfer training.

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: 06/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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: 06/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/10/2026
Section Cited
CCR
87468.1
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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:
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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 06/10/26 to Elvira.Gonzalez@DSS.CA.GOV
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Based on records reviewed, and interviews conducted, the Licensee failed to adequately supervise (R1) on 09/17/25, and 09/29/25, allowing them to wander the community unaccompanied by staff, which resulted in R1 suffering two unwitnessed falls and sustaining a head injury and a laceration of scalp that led to hospitalization. This violation poses an immediate health and safety risk to residents in care.
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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: 06/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5