198320398-9-3-2026-11-AS-UCOL-DXLM5U-20260904091854

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320398
Report Date: 09/03/2026
Date Signed: 09/03/2026 02:42:54 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 COGIR		FACILITY NUMBER:	198320398
ADMINISTRATOR:	JULIUS OSORIO		FACILITY TYPE:	740
ADDRESS:	27520 HAWTHORNE BOULEVARD		TELEPHONE:	(310) 697-6236
CITY:	ROLLING HILLS ESTATE	STATE: CA	ZIP CODE:	90274
CAPACITY:	121	CENSUS: 90	DATE:	09/03/2026
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Julius Osorio - Executive Director		TIME COMPLETED:	03:00 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 09/03/26 Licensing Proulgram Analyst (LPA) Mario Leon conducted an unannounced, subsequent, complaint visit at the facility to deliver an updated complaint investigation report. The purpose of today's report is to provide additional information only; the findings remain as Unsubstantiated.
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 medication administration record (MAR) of two residents (R1-R2) (dated: September through November, 2025). 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/Face sheets (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: 09/03/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2026

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 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: 09/03/2026

NARRATIVE

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The investigation revealed the following:
Regarding the allegation “Staff neglect resulted in a resident sustaining a pressure injury”, it is being alleged that due to staff neglect resident R1 has developed a pressure injury. Record reviews indicate that R1 began receiving wound-care visits on 10/23/25. Records also show that on 11/07/25, R1 was admitted to Beacon Hospice Care Inc. for hospice services. Interviews revealed that six out of six residents (R2-R7), one (1) witness (W1) and four out of four staff (S2-S5) interviewed have denied the allegation. 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 did reposition residents on a regular basis. Record reviews revealed the following: On 11/07/25 Beacon Hospice Care Inc.’s hospice care plan indicates that staff are to reposition R1 at least once every two (2) hours, as tolerated. Interviews revealed that six out of six residents (R2-R7), one (1) witness (W1) and four out of four staff (S2-S5) interviewed have denied the allegation. 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 (R1) is not receiving wound care for their injury. Record reviews indicate that R1 began receiving wound-care visits on 10/23/25. Records also show that on 11/07/25, R1 was admitted to Beacon Hospice Care Inc. for hospice services. Records indicate that Beacon Hospice Care Inc. staff visited R1 on: 11/07/25, 11/09/25, 11/12/25, 11/13/25, 11/18/25, 11/20/25, and 11/21/25. Interviews revealed that all six (6) residents (R2-R7), one (1) witness (W1) and all four (4) staff (S2-S5) have denied the allegation. 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: 08/27/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2026

LIC9099 (FAS) - (06/04)

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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: 09/03/2026

NARRATIVE

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Regarding the allegation that “Staff mishandled a resident’s medications,” it is alleged that resident’s medications are not administered as prescribed. Record reviews of R1’s Medication Administration Record indicate that all oral medications were discontinued on 11/16/25. Documentation from Beacon Hospice Care Inc. on 11/17/25 shows that R1’s oral medications were discontinued due to a risk of aspiration. The physician recorded that R1 was “nothing by mouth” (NPO) except for comfort medications as of 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 staff neglected R1’s needs. Observations revealed the following: CDSS observed staff’s average response time to a resident’s call button to be 11 to 15 minutes. Records reviews revealed the following: On 11/07/25 Beacon Hospice Care Inc.’s hospice care plan indicates that staff are to reposition R1 at least once every two (2) hours, as tolerated. Interviews revealed that six out of six residents (R2-R7), one (1) witness (W1) and four out of four staff (S2-S5) interviewed have denied the allegation. Based on observations, 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 Julius Osorio - Executive Director and a copy of this report has been provided.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2026

LIC9099 (FAS) - (06/04)

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