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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197800131
Report Date: 08/29/2025
Date Signed: 08/29/2025 10:34:53 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/31/2025 and conducted by Evaluator Socorro Leandro
COMPLAINT CONTROL NUMBER: 11-AS-20250131083643
FACILITY NAME:CHATEAU LONG BEACHFACILITY NUMBER:
197800131
ADMINISTRATOR:ESPERANZA NAAKTGEBORENFACILITY TYPE:
740
ADDRESS:3100 E. ARTESIA BLVD.TELEPHONE:
(562) 428-5371
CITY:LONG BEACHSTATE: CAZIP CODE:
90805
CAPACITY:184CENSUS: 106DATE:
08/29/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Assistant Administrator - Olivia AlvaradoTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Resident developed stage 3 pressure injury while in care.
Licensee is retaining a resident with a higher level of care need.
INVESTIGATION FINDINGS:
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On 08/29/2025, Licensing Program Analyst (LPA) Socorro Leandro conducted a subsequent visit on to deliver findings regarding the allegations listed above. LPA met with Assistant Administrator, Olivia Alvarado and the purpose of the visit was explained. LPA was granted entry to the facility.

Investigation consisted of the following:

On 02/03/2025, the department requested and gathered Resident 1’s (R1) records. R1’s records consisted of: Admission Agreement dated 10/18/2025; Personal Rights dated 10/18/2025; Identification and Emergency Information dated 10/18/2025; Physician’s Report dated 10/15/2024; and other pertinent information. From 02/20/2025 to 04/29/2025, department interviewed Resident 1 (R1) to Resident 3 (R3), Staff 1 (S1) to Staff 6 (S6), and Witness 1 (W1). On 07/31/2025, the department reviewed the Investigation Case Report along with Attachments dated 05/19/2025.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025
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-20250131083643
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CHATEAU LONG BEACH
FACILITY NUMBER: 197800131
VISIT DATE: 08/29/2025
NARRATIVE
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Investigation revealed the following:

Allegation: “Resident developed stage 3 pressure injury while in care”, it is being alleged that R1 developed a stage 3 pressure injury while in care. Records reviewed revealed the following: Physicians Report dated 10/15/2024 indicates that R1 has a history of pressure injuries. R1’s Admission Agreement is dated 10/18/2024. R1 began Home Health on 11/10/2024 and the report indicates that R1 had a risk of pressure injuries but had no pressure injuries at the time of assessment and the goal for R1 was not to develop any pressure injury. From 11/10/2024 to 12/24/2024, R1 received Home Health services; Home Health staff instructed facility caregivers to check skin for any signs of pressure injuries and change position of R1 every two hours. R1 was hospitalized on 12/24/2024 and was discharged on 12/28/2024. There are no records of Home Health services provided to R1 from 12/25/2024 to 01/28/2025. On 12/28/2024, Progress Notes indicates that the Primary Physician diagnosed R1 with a stage 2 sacral decubitus ulcer measuring 0.5cmx0.5cmx0.1cm, there is no documentation indicating that R1’s Primary Physician performed wound care from 12/28/2024 to 01/28/2025. The facility did not maintain a record of R1 being repositioned every two hours or of care provided with all aspects R1’s pressure injury. On 01/28/2025, hospital and medical records indicate that during admission R1 was diagnosed with stage 3 and stage 4 pressure injuries in the buttocks area. Interviews conducted revealed the following: On 02/27/2025, R1 confirmed that staff would not reposition them every two hours. On 04/29/2025, 2 out of 6 staff indicated that staff would not reposition residents if they were in wheelchairs, unless residents requested it; 5 out of 6 staff confirmed that on December 2024 they saw an injury (e.g., the size of a bean, Q-Tip, and quarter) right above R1’s behind (e.g., buttock, coccyx). Based on interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An immediate civil penalty of $500.00 is being assessed please see LIC421IM.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20250131083643
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CHATEAU LONG BEACH
FACILITY NUMBER: 197800131
VISIT DATE: 08/29/2025
NARRATIVE
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Allegation: “Licensee is retaining a resident with a higher level of care need”, it is being alleged that R1 was retained at the facility even though R1 required a higher level of care. Records reviewed revealed the following: Physicians Report dated 10/15/2024 indicates that R1 has a history of pressure injuries. R1’s Admission Agreement is dated 10/18/2024. R1 began Home Health on 11/10/2024 and the report indicates that R1 had a risk of pressure injuries and the goal for R1 was not to develop any pressure injury. R1 was hospitalized on 12/24/2024 and was discharged on 12/28/2024. On 12/28/2024, Primary Physician Progress Notes diagnosis R1 with a stage 2 sacral decubitus ulcer measuring 0.5cmx0.5cmx0.1cm. There are no records of Home Health services provided to R1 from 12/25/2024 to 01/28/2025. From 12/28/2024 to 01/28/2025, there is no documentation indicating that R1’s Primary Physician performed wound care. The facility did not maintain a record of R1 being repositioned every two hours and did not provide documentation of all aspects of care performed to address R1’s pressure injury. On 01/28/2025, hospital and medical records indicate that during admission R1 was diagnosed with stage 3 and stage 4 pressure injuries in the buttocks area. Interviews conducted revealed the following: On 02/27/2025, R1 confirmed that they developed a pressure injury while in care at the facility. On 04/29/2025, 5 out of 6 staff confirmed that on December 2024 they saw a pressure injury (e.g., the size of a bean, Q-Tip, and quarter) right above R1’s behind (e.g., buttock, coccyx); 2 out of 6 staff confirmed that on December 2024, after R1 came back from the hospital (on 12/28/2024), R1 was no longer receiving Home Health services. Based on interviews and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20250131083643
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CHATEAU LONG BEACH
FACILITY NUMBER: 197800131
VISIT DATE: 08/29/2025
NARRATIVE
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Deficiencies were cited.

At this time, an additional civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.”

An exit interview was conducted, and a plan of correction was developed. A copy of this report and appeal rights were provided to the Assistant Administrator, Olivia Alvarado.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20250131083643
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: CHATEAU LONG BEACH
FACILITY NUMBER: 197800131
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/30/2025
Section Cited
CCR
87615(a)(1)
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87615 Prohibited Health Conditions (a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries.

This requirement is not met as evidenced by:
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The Assistant Administrator, Olivia Alvarado agreed to create a plan to ensure that the facility will not admit or retain residents with stage 3 or stage 4 pressure injuries. Proof of corrections will be emailed to Socorro.Leandro@dss.ca.gov.
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Based on interviews and records reviewed, the licensee did not comply with the section cited above.
On 01/28/2025, upon arrival to the hospital, R1 was diagnosed with stage 3 and stage 4 pressure injuries near the buttock area. The licensee retained R1 while having a stage 3 pressure injury while in care. This poses an immediate health, safety or personal rights risk to persons in care.
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Type A
08/30/2025
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.

This requirement is not met as evidenced by:
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The Assistant Administrator, Olivia Alvarado agreed to create a plan to ensure that residents with stage 1 and stage 2 pressure injuries receive continuous wound care with skilled professionals (e.g. Home Health, Physician, LVNs, Palliative Care, Hospice Care).
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Based on interviews and records reviewed, the licensee did not comply with the section cited above. The licensee did not ensure that R1 received wound care services from 12/28/2024 to 1/28/2025 which resulted to R1 developing stage 3 and stage 4 pressure injuries while in care. This poses an immediate health, safety or personal rights risk to persons in care.
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 Proof of corrections will be emailed to Socorro.Leandro@dss.ca.gov .
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: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5