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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608888
Report Date: 05/04/2026
Date Signed: 05/04/2026 10:49:47 AM

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
03/10/2026 and conducted by Evaluator Felisa Shirley
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20260310162603
FACILITY NAME:WEST PICO TERRACE ASSISTED LIVING CENTER LPFACILITY NUMBER:
197608888
ADMINISTRATOR:AZUCENA REYES SERRANOFACILITY TYPE:
740
ADDRESS:6050 W PICO BLVDTELEPHONE:
(323) 653-5565
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:136CENSUS: 88DATE:
05/04/2026
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Azucena Reyes - AdministratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff are not responding to residents call button.
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 3/17/26.

On 3/17/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Wellness Director, Sheila Sikula 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 3/17/26, LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Medical Administration Records for Feb/26 and Mar/26, handwritten records of medication from R1. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff- 6 (S1 – S6), and Resident -1 – Resident -8 (R1-R8).
Con'd on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026
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-20260310162603
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: 05/04/2026
NARRATIVE
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The investigation revealed the following:

Allegation: Staff are not responding to residents call button.

It is being reported that it takes staff up to 2 hours to respond to the resident’s call button. Per LPA Felisa Shirley’s observation, the resident call system is stationed in 2 locations within the facility, one place is in the med tech room and the second is in the 3rd floor dining room. LPA Shirley interviewed S1 on 3/17/26, S1 stated that when call button alerts are received, receiving staff uses the walkie to dispatch the caregiver assigned for residents in that specific area on the walkie and the responding caregiver is immediately notified of the resident’s location. LPA Shirley toured the facility and pushed the call button in R1’s assigned room at 10:01am and noted that it took receiving staff 3 minutes to respond and arrived at R1’s room at 10:04am. Per interview with S1, if there is a shortage of staff when an alert comes in from a resident, she sometimes identify who the resident is on the alert panel and responds to the alert herself to help out. Per interviews with S1-S6, there is no tracking system in place to verify response times for call button alerts from residents.

LPA interviewed staff 1 – staff 6 (S-1 – S-6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 1 – resident 8 (R1 – R8). Of those who interviewed 2 out of 8 denied the allegation. Two residents confirmed the allegation, and 4 residents neither denied nor confirmed the allegation.

Based on information gathered, LPA did not find sufficient evidence to support the allegation “Staff are not responding to residents call button,” 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, Azucena Reyes, Administrator.

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

DATE: 05/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
03/10/2026 and conducted by Evaluator Felisa Shirley
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20260310162603

FACILITY NAME:WEST PICO TERRACE ASSISTED LIVING CENTER LPFACILITY NUMBER:
197608888
ADMINISTRATOR:AZUCENA REYES SERRANOFACILITY TYPE:
740
ADDRESS:6050 W PICO BLVDTELEPHONE:
(323) 653-5565
CITY:LOS ANGELESSTATE: CAZIP CODE:
90035
CAPACITY:136CENSUS: 88DATE:
05/04/2026
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Azucena Reyes - AdministratorTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
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8
9
Staff did not administer medication to residents in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
* This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 3/17/26.

On 3/17/26, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by the Wellness Director, Sheila Sikula 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 3/17/26, LPA Shirley reviewed copies of the following records: Staff and Resident Roster, Medical Administration Records for Feb/26 and Mar/26, handwritten records of medication from R1. LPA Felisa Shirley conducted a tour of the facility. LPA Shirley interviewed Staff 1 – Staff- 6 (S1 – S6), and Resident -1 – Resident -8 (R1-R8).
Con'd on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20260310162603
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: 05/04/2026
NARRATIVE
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Allegation: Staff did not administer medication to residents in care.

It is being reported that R1 stated that medication administration is timely, but the total daily dose is inconsistent. Per review of March 2026 Medical Administration Record, the (MAR) on 3/17/26, LPA Felisa Shirley observed that as of 3/17/26, R1 has 28 active medications and 10 PRN’s. On 3/17/2026, LPA Shirley reviewed the MAR for R1 and noted that for the date of 3/16/2026, MAR had no initials for pantoprazole, however, the medication was not in bubble pack. For 3/17/2026, MAR had no initials for pantoprazole AM dose and medication was still in the bubble pack.

LPA interviewed staff 1 – staff 6 (S-1 – S-6). Of those interviewed 6 out of 6 denied the allegation. LPA interviewed resident 1 – resident 8(R1 – R8). Of those who interviewed 7 out of 8 denied the allegation. One resident confirmed the allegation.


According to the information gathered there is sufficient evidence to support the allegation “Staff did not administer medication to residents in care”. Based on interview and record review the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8.

Deficiencies are issued and an exit interview is conducted with Azucena Reyes, Administrator . A copy of this report and appeal rights were provided.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20260310162603
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: 05/04/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/31/2026
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care. (4) The licensee shall assist residents with self-administered medications as needed.


This requirement was not met as evidenced by:
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The Administrator shall submit plan informing the department medication training has been performed with all staff. A written proof of correction must included along with date, time and participants names. Correction must be submitted by due date: 3/31/26 to LPA's email: felisa.shirley@dss.ca.gov or fax attn: to LPA Felisa Shirley to 424-544-1016.
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Based on records reviewed on 3/17/2026, LPA Shirley reviewed facility medication administration records (MAR) for R1 and noted that for the date of 3/16/2026, MAR had no initials for pantoprazole, but medication was not in bubble pack. For 3/17/2026, MAR had no initials for pantoprazole AM dose and medication was still in the bubble pack. This action poses as a potential health and safety risk to persons 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: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5