197610251-3-5-2026-31-AS-TAGD-DT7NKS-20260416103221

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197610251
Report Date: 03/05/2026
Date Signed: 03/05/2026 12:46:02 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/08/2025 and conducted by Evaluator Angelica Segovia

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20250508155156

FACILITY NAME:	MONDELL PINE MANOR I		FACILITY NUMBER:	197610251
ADMINISTRATOR:	SOLIS, CANDICE		FACILITY TYPE:	740
ADDRESS:	39046 MONDELL PINE AVE		TELEPHONE:	(805) 468-5068
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	6	CENSUS: 6	DATE:	03/05/2026
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Richard Garcia- House Manager		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Resident sustained Stage 3 Pressure injuries while in care.
Staff did not ensure resident's diapering needs were properly met.

INVESTIGATION FINDINGS:

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On 03/05/2026 at approximately 10:30 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced subsequent complaint visit. LPA was greeted by staff and stated the reason for their visit. The House Manager, Richard Garcia arrived shortly after to assist with today’s visit.

On 05/08/2025 the Woodland Hills South Adult and Senior Regional Office received a complaint alleging the neglect and lack of care from the facility staff resulted in a resident developing pressure injuries. On 5/09/2025, LPA Melissa Spaeth conducted the initial twenty-four (24) hour complaint investigation visit. On 5/12/2025 the complaint was referred to the Community Care Licensing Investigation Branch and accepted as an investigation. The complaint was assigned to Investigator with the California Department of Social Services (CDSS) Laura Garcia (IB).

(Continue 9099-C)

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026

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 6

Control Number 31-AS-20250508155156

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MONDELL PINE MANOR I	FACILITY NUMBER: 197610251
	VISIT DATE: 03/05/2026

NARRATIVE

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The investigation determined the following:

Regarding the allegation: Resident sustained Stage 3 Pressure injuries while in care. It was alleged that Resident 1 (R1) sustained pressure injuries due to the neglect and the lack of care from the facility staff. To investigate the allegation, IB Garcia conducted interviews with three staff members (S1-S3) between the dates of 6/13/2025 to 11/18/2025. IB Garcia’s interview with S1 revealed that staff are required to conduct sponge baths to all residents every day. S1 confirmed that R1 did not have home health or a wound care plan in place. Further interview with S1 revealed that, “…the incident was a lesson for them”. IB Garcia’s interview with S2 revealed that R1’s pressure wounds would emit unpleasant odors along with discoloration, yet they did not seek out any medical assistance for R1’s wound. Additionally, S2 was also unable to provide any body-check logs pertaining to R1. IB Garcia’s interview with S3 revealed that they did not conduct body checks on R1, yet they noticed redness around R1’s pelvic area but did not seek out medical treatment. On 05/09/2025, Special Investigator Assistant (SIA) Amina Luckett subpoenaed R1’s medical records from Palmdale Regional Medical Center. IB Garcia’s record review revealed R1 was admitted on 4/18/2025 where they were examined and the following was observed: a diabetic ulcer to their left heel, a pressure wound to the right lateral ankle measuring, an unstageable pressure wound to the sacrum measuring and moisture-associated skin damage (MASD) to peri wounds.

Furthermore, based on IB’s investigation there is enough evidence to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Regarding the allegation: Staff did not ensure resident's diapering needs were properly met. It was alleged that staff did not ensure R1’s diapering needs were properly met. To investigate the allegation, IB Garcia conducted interviews with three staff members (S1-S3) between the dates of 6/13/2025 to 11/18/2025. IB Garcia’s interview with S2 revealed that they failed to check R1 every two hours during their nightshift to see if they required a change in diapering. IB Garcia’s interview with S3 revealed that they would change R1’s diaper when it was “almost leaking” due to R1’s refusal to be changed. Interviews with both S2 and S3 revealed that R1 was capable of requesting when their diaper needed to be changed, however IB Garcia notated that due to R1’s cognitive diagnosis they could not be interviewed. LPA Segovia’s record review on 12/09/2025 of R1’s Physician Report confirmed that R1 had been documented to have cognitive impairments.

(Continue to LIC 9099-C)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20250508155156

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MONDELL PINE MANOR I	FACILITY NUMBER: 197610251
	VISIT DATE: 03/05/2026

NARRATIVE

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Based on record review and IB’s investigation there is enough evidence to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time.

Citation issued, please refer to LIC 9099-D. Civil penalty assessed. An immediate civil penalty of $500 was assessed today for a violation resulting in an immediate hazard to the health and safety of R1. The House Manager was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f).

No other immediate health and safety hazards observed during the time of the visit.

Exit interview was conducted, appeal rights were given, and a copy of the report was provided to the House Manager, Richard Garcia

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 31-AS-20250508155156

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MONDELL PINE MANOR I	FACILITY NUMBER: 197610251
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/05/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/06/2026 Section Cited CCR 87615(a)(1)	1 2 3 4 5 6 7	87615 Prohibited Health Conditions. (a) Persons who require health services for or have a health condition including...shall not be...retained in a residential care facility for the elderly:(1) Stage 3 and 4 pressure injuries. This requirement was not met evidence by:	1 2 3 4 5 6 7	The Administrator will review the regulation and email LPA Segovia a statement of understanding with current in-service training regarding care of residents to include body check logs for residents by POC due date.
	8 9 10 11 12 13 14	Based on IB's investigation, due to the lack and care of facility staff, R1 developed pressure injuries which poses an immediate Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14
Type A 03/06/2026 Section Cited CCR 87464(d)	1 2 3 4 5 6 7	87464 Basic Services. (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs... This requirement was not met evidence by:	1 2 3 4 5 6 7	The Administrator will review the regulation and email LPA Segovia a statement of understanding with current in-service training regarding care of residents to include incontinence needs by POC due date.
	8 9 10 11 12 13 14	Based on interviews, record review and IB's investigation, facility staff failed to meet R1's needs such as diaper changes which resulted in R1's hospitalizations which poses an immediate Health, Safety, or Personal Rights risk to persons in care.	8 9 10 11 12 13 14

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: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/08/2025 and conducted by Evaluator Angelica Segovia

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20250508155156

FACILITY NAME:	MONDELL PINE MANOR I		FACILITY NUMBER:	197610251
ADMINISTRATOR:	SOLIS, CANDICE		FACILITY TYPE:	740
ADDRESS:	39046 MONDELL PINE AVE		TELEPHONE:	(805) 468-5068
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY:	6	CENSUS: 6	DATE:	03/05/2026
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Richard Garcia- House Manager		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

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Staff did not safeguard resident's personal items.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 31-AS-20250508155156

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MONDELL PINE MANOR I	FACILITY NUMBER: 197610251
	VISIT DATE: 03/05/2026

NARRATIVE

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Regarding the allegation: Staff did not safeguard resident's personal items. It was alleged that facility staff failed to care for R1’s personal belongings. To investigate the allegation, LPA Segovia attempted interviews with seven (7) residents and four (4) staff members. Per the Reporting Party (RP), three (3) clothing items belonging to R1 were damaged and stained with bleach. LPA’s interview with three (3) residents revealed that staff have not damaged their personal property such as clothing. LPA attempted to interview R1, but they no longer reside at the facility. LPA attempted to interview R5 but due to their inability to validate the questions being asked, LPA terminated the interview. LPA attempted to interview R6 and R7, but they were asleep during LPA’s visit. LPA’s interview with S1 revealed that R1’s damaged clothing was never brought to their attention, nor had they witnessed R1’s clothing to be damaged. LPA’s interview with both S1 and S4 confirmed residents’ clothing are washed everyday with no issues. LPA attempted to interview S2, but they no longer work at the facility. LPA attempted to interview S3, but they were not present during LPA’s visit. During LPA’s physical plant tour, LPA observed residents to be dressed appropriately and well groomed. LPA did not observe any damage to their clothing. LPA observed the laundry appliances to be working and in proper condition.

Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No other immediate health and safety hazards observed during the time of the visit.

Exit interview was conducted, and a copy of the report was provided to the House Manager.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026

LIC9099 (FAS) - (06/04)

Page: 6 of 6