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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204972
Report Date: 07/22/2026
Date Signed: 07/22/2026 04:12:45 PM

Unsubstantiated


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
07/15/2026 and conducted by Evaluator Felisa Shirley
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20260715132715
FACILITY NAME:ROSECRANS VILLA RESIDENTIAL CAREFACILITY NUMBER:
198204972
ADMINISTRATOR:SANDRA LOPEZFACILITY TYPE:
740
ADDRESS:14110 CORDARY AVENUETELEPHONE:
(310) 675-9163
CITY:HAWTHORNESTATE: CAZIP CODE:
90250
CAPACITY:135CENSUS: 110DATE:
07/22/2026
UNANNOUNCEDTIME BEGAN:
08:28 AM
MET WITH:Administrator, Sandra LopezTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff did not prevent residents from attacking other residents
Staff filed a false 5150 report on a resident
Staff do not safeguard residents' personal belongings
INVESTIGATION FINDINGS:
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On 7/22/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Administrator, Sandra Lopez and explained the purpose of the visit is to investigate and deliver findings for the allegations mentioned above. LPA was granted access to the facility.

The investigation consisted of the following:
On 7/22/26 LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Admissions Agreement, Identification and Emergency Contact, Medical Assessment for Residential Care Facilities for the Elderly, Appraisal/Needs and Services Plan, Unusual Incident/Injury Report, Copy of Hawthorne P.D. Business Card, Application for up to 72 Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment and Administrator’s Progress Records. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff 8 (S1 – S8), and Resident 1 – Resident 6 (R1-R6).

Con'd on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2026
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-20260715132715
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: ROSECRANS VILLA RESIDENTIAL CARE
FACILITY NUMBER: 198204972
VISIT DATE: 07/22/2026
NARRATIVE
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The investigation revealed the following:

Allegation: Staff did not prevent residents from attacking other residents

It is being alleged that R1’s walking cane accidentally touched R6 as R1 was getting his food. On 7/22/26, LPA Felisa Shirley reviewed a Shift Report dated 5/31/26 written by S3. S3 reported that R1 was observed being aggressive with R6 as R1’s walking cane hit R6 as he squatted on floor near the dining room. Per interview with R1 on 7/22/26, R6 was sitting directly in front of R1’s room. R1 stated that the incident was a verbal altercation as R1 told R6 to not block his room door as R1 is totally blind. R1 stated that R6 jumped up and began threatening him. R1 stated that he went into his room to avoid R6 and called Hawthorne P.D. LPA Shirley requested to view the incident on video and was told by the Administrator that she did not have access to retrieve the footage back to the incident date of 5/31/26. The Administrator further advised LPA Shirley that the camera installer informed her that the surveillance camera system can only store recorded video for up to two weeks. During interview with S7 on 7/22/26, S7 went to R1’s room to assess his condition and determine the cause of his distress. As S7 attempted to gather additional information, R1 became increasingly agitated and began screaming in his room. LPA Shirley interviewed R6 on 7/22/26, regarding the reported altercation. When asked about the incident, the resident stated that they did not recall the altercation and was unable to provide any additional details.

LPA interviewed staff 1 – staff 8 (S1 – S8). Of those interviewed 8 out of 8 denied the allegation. LPA interviewed resident 1 – resident 6 (R1 – R6). Of those who interviewed 5 out of 6 denied the allegation. One resident confirmed the allegation and stated that it’s hard to explain, then they ended the interview.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff did not prevent residents from attacking other residents,” therefore, the allegation is unsubstantiated.

Allegation: Staff filed a false 5150 report on a resident

It is being alleged that R1 was put on a 72-hour 5150 hold. On 7/22/26, LPA Shirley observed an incident report dated 6/3/26, stating that R1 was placed on a 5150 hold by the Psychiatric Emergency Team, (PET) on 6/1/26, by the clinician due to R1 being a danger to others and escalating aggressive behaviors. During file review, LPA Shirley

Con'd on 9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20260715132715
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: ROSECRANS VILLA RESIDENTIAL CARE
FACILITY NUMBER: 198204972
VISIT DATE: 07/22/2026
NARRATIVE
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observed the Application for up to 72 Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment dated 6/1/26, due to escalating aggressive behavior and recent attempts to physically assault another resident. LPA Shirley received and reviewed a Shift Report written by S2 on 6/1/26, stating staff reported multiple incidents of unprovoked aggressive behavior from R1. Per interview with R1 on 7/22/26, R6 was sitting directly in front of R1’s room. R1 stated that the incident was a verbal altercation as R1 told R6 to not block his room door as R1 is totally blind. R1 stated that R6 jumped up and began threatening him. R1 stated that he went into his room to avoid R6 and called Hawthorne P. D. Per interview with the Administrator, S1 on 7/22/26, R1 accidentally hit R6 with his cane and became very upset and aggressive. S1 stated that R1 didn’t want to speak to anyone. R1 would not open his door. R1 called the Hawthorne P. D. S1 stated that she facetimed the clinician. The clinician remained on the phone throughout the entire incident and directly witnessed and observed all events as they occurred. Based on his assessment of the situation, he made the clinical decision to place R1 on a 5150 involuntary psychiatric hold.

LPA interviewed staff 1 – staff 8 (S1 – S8). Of those interviewed 8 out of 8 denied the allegation. One staff did not know. LPA interviewed resident 1 – resident 6 (R1 – R6). Of those who interviewed 4 out of 6 denied the allegation. One resident confirmed it and 1 didn’t want to talk.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff filed a false 5150 report on a resident,” therefore, the allegation is unsubstantiated.

Allegation: Staff do not safeguard residents' personal belongings

It is being alleged that when R1 returned to the facility from the 5150 hold on 6/8/26, when he discovered that his refrigerator was turned off causing his food to spoil. On 7/22/26, LPA Shirley observed an incident report dated 6/3/26, stating that R1 was placed on a hold by the Psychiatric Emergency Team, (PET), clinician due to R1 being a danger to others and escalating aggressive behaviors. Per interview with R1 on 7/22/26, R1 was placed on a 5150

Con'd on 9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20260715132715
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: ROSECRANS VILLA RESIDENTIAL CARE
FACILITY NUMBER: 198204972
VISIT DATE: 07/22/2026
NARRATIVE
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psychiatric hold from 6/1/26 to 6/8/26. Upon returning to the facility, R1 stated that the Administrator, S1, had instructed S8 to turn R1’s refrigerator off in his absence. LPA Shirley interviewed S8 on 7/22/26, and S8 verified that she was not asked to turn off R1’s refrigerator. During file review on 7/22/26, LPA Shirley observed a progress record from the Administrator dated 6/9/26, stating upon R1 returning from his 5150 hold, R1 reported that his cellphone was missing. Over the following 2 days, the Administrator attempted to contact the phone on multiple occasions but received no answer. R1 came to the front office, at which time the Administrator called R1’s phone and heard it ringing on R1’s person. On 6/11/26, R1 informed the Administrator that he had located his phone. R1 stated that he had forgotten where he left the phone prior to going to the hospital.

LPA interviewed staff 1 – staff 8 (S1 – S8). Of those interviewed 8 out of 8 denied the allegation. LPA interviewed resident 1 – resident 6 (R1 – R6). Of those who interviewed 5 out of 6 denied the allegation. One stated again, she didn’t want to talk

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff do not safeguard residents' personal belongings,” therefore, the allegation is unsubstantiated.

No deficiencies were cited for these allegations.

An exit interview was conducted and a copy of this report was provided to the Administrator, Sandra Lopez.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/22/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4