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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320398
Report Date: 07/21/2026
Date Signed: 07/21/2026 12:23:01 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
11/17/2025 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20251117223742
FACILITY NAME:PENINSULA POINTE BY COGIRFACILITY NUMBER:
198320398
ADMINISTRATOR:JULIUS OSORIOFACILITY TYPE:
740
ADDRESS:27520 HAWTHORNE BOULEVARDTELEPHONE:
(310) 697-6236
CITY:ROLLING HILLS ESTATESTATE: CAZIP CODE:
90274
CAPACITY:121CENSUS: 87DATE:
07/21/2026
UNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Erica Lombardo - Business DirectorTIME COMPLETED:
12:44 PM
ALLEGATION(S):
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Staff neglect resulted in a resident sustaining a pressure injury
Staff do not properly reposition a resident while in care
Staff do not timely address a resident's change in medical condition
Staff mishandled a resident's medications
Staff do not provide adequate care and supervision to a resident
INVESTIGATION FINDINGS:
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On 07/21/26 Licensing Program Analyst (LPA) Mario Leon conducted an unannouned, subsequent, complaint visit at the facility to conduct additional interviews and to deliver findings.
California Department of Social Services (CDSS) was met by staff two, Erica Lombardo - Business Director (S2) and the purpose of the visit was explained.
The investigation consisted of the following:
On 07/21/26 CDSS requested staff and resident rosters (dated: 07/21/26) and between 9:30AM and 11:30AM, CDSS interviewed six (6) residents (R2-R7) and two (2) staff (S6-S7). On 07/08/26 CDSS requested hospice notes of R1 (Dated 11/09/25) and three months medication administration record (MAR) of two residents (R1-R2) (dated: September through November, 2025). Between 11:00AM and 3:30PM, CDSS interviewed six (6) residents (R2-R7) and four (4) staff (S2-S5). On 11/19/25 CDSS requested resident and staff rosters (dated: 11/25) and documents listed for residents one (1) through four (4) (R1-R4), listed as follows: Medical Assessments (R1-R4), Care Plans (R1-R4), Medication Administration Records (MARs) for the past seven (7) days (R1-R4), Emergency ID/Facesheets (R1-R4) and Admissions Agreements (R1-R4). Report continues, please see LIC9099-C.
Unsubstantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026
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 3
Control Number 11-AS-20251117223742
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: PENINSULA POINTE BY COGIR
FACILITY NUMBER: 198320398
VISIT DATE: 07/21/2026
NARRATIVE
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Regarding the allegation “Staff neglect resulted in a resident sustaining a pressure injury”, it is being alleged that due to staff neglect a resident has developed a pressure injury. Record reviews of the resident’s files have indicated that resident one (R1) has been visited by a hospice agency, beginning on 11/07/26. The number of visits are listed as follows: 11/07/25, 11/09/25, 11/12/25, 11/13/25, 11/18/25, 11/20/25, 11/21/25. During these visits R1 has received wound care and skin protectant has been applied, along with other physician’s orders which include repositioning R1 at least once every two hours. Interviews revealed that all six (6) residents (R2-R7), one (1) witness (W1) and all four (4) staff (S2-S5) have denied the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

Regarding the allegation “Staff do not properly reposition a resident while in care”, it is being alleged that staff rarely reposition residents in care. Record reviews of Beacon Hospice Care Inc. have indicated that staff are to reposition a resident at least once every two hours. Interviews revealed that all six (6) residents, one (1) witness and all four (4) staff have denied the allegation has taken place. Due to R1 having always been together with family (R2), family has reported any discomfort R1 has had. Furthermore, W1 has clarified that they too were present during the period of November, 2025. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

Regarding the allegation “Staff do not timely address a resident's change in medical condition”, it is being alleged that a resident is not receiving wound care for their injury. Record reviews of Beacon Hospice Care Inc. have indicated that resident has been visited by a hospice agency, beginning on 11/07/26. The number of visits are listed as follows: 11/07/25, 11/09/25, 11/12/25, 11/13/25, 11/18/25, 11/20/25, 11/21/25. Furthermore, R1 has also been visited by a home health agency, prior to hospice initiation, on 10/23/25 for wound care. Interviews revealed that all six (6) residents (R2-R7), one (1) witness (W1) and all four (4) staff (S2-S5) have denied the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated. Report continues, please see LIC9099-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20251117223742
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: PENINSULA POINTE BY COGIR
FACILITY NUMBER: 198320398
VISIT DATE: 07/21/2026
NARRATIVE
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Regarding the allegation “Staff mishandled a resident's medications”, it is being alleged that a resident’s medication is not being provided as prescribed. Record reviews have indicated that R1’s medication was discontinued on 11/16/25. Physician’s orders, from Beacon Hospice Care Inc., have indicated that R1 is “nothing by mouth” (NPO) except comfort medication on 11/17/25. Interviews revealed that all six (6) residents, one (1) witness and all four (4) staff have denied the allegation has taken place. Based on record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

Regarding the allegation “Staff do not provide adequate care and supervision to a resident”, it is being alleged that a resident is not receiving proper care and supervision regarding their current situation. Record reviews of physician’s orders have indicated that staff are to reposition a resident at least once every two hours. CDSS observed staff’s average response time to a resident’s call button to be 13 minutes. Interviews revealed that all six (6) residents, one (1) witness and all four (4) staff have denied the allegation has taken place. Due to R1 having always been together with family (R2), family has reported any discomfort R1 has had. Furthermore, W1 has clarified that they too were present during the period of November, 2025. Based on CDSS observation, record reviews and interviews conducted, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the above allegation has been Unsubstantiated.

There have been zero (0) deficiencies cited during today's visit.

An exit interview was held with staff two, Erica Lombardo - Business Director (S2), and a copy of this report has been provided.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3