197800131-12-2-2025-11-AS-RORN-DQHSRD-20260120130611

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197800131
Report Date: 12/02/2025
Date Signed: 12/02/2025 05:07:49 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, 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
11/24/2025 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20251124120413

FACILITY NAME:	CHATEAU LONG BEACH		FACILITY NUMBER:	197800131
ADMINISTRATOR:	ESPERANZA NAAKTGEBOREN		FACILITY TYPE:	740
ADDRESS:	3100 E. ARTESIA BLVD.		TELEPHONE:	(562) 428-5371
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90805
CAPACITY:	184	CENSUS:	DATE:	12/02/2025
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:			TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff neglect during transfer resulted in the resident being dropped

INVESTIGATION FINDINGS:

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On 12/02/2025, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Complaint Visit to the facility listed above. LPA met with Executive Director, Esperanza Naaktgeboren, and the purpose of today’s visit was explained. LPA was granted entry into the facility.

The investigation consisted of the following:

During today’s visit, LPA inspected the facility, interviewed Staff S1-S8, interviewed Residents R1-R10, and received and reviewed the following documents Staff Roster, Resident Roster, Identification and Emergency Information, Physician’s Report, Individual Service Plan, Admission Agreement, Daily Logs, Hospice Orders, Outside Agency Documentation, Staff Training Logs, and Staff In-Service Training Logs.

The investigation revealed the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025

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-20251124120413

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: 12/02/2025

NARRATIVE

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Allegation: Staff neglect during transfer resulted in a resident being dropped.
The allegation alleges that while being transferred with a Hoyer Lift it broke, and the resident fell to the ground.

During the facility inspection LPA observed a Hoyer Lift in R1’s room that was operating properly.

During record review, LPA received and reviewed the Daily Logs, that indicates on 06/04/2025, R1 was observed sliding out of their wheelchair, an additional staff was called to assist with helping R1 to be lowered to the ground. Then the Hoyer Lift was used to transfer R1 to their bed. LPA observed during record review that the Hoyer Lift(s) were provided through R1’s former hospice agency and their medical program. Additionally, during record review, LPA received and reviewed Staff In-Service Logs, dated 05/22/2025, and material regarding Assisting with Proper Positioning, Commonly Used Mobility Devices, and Hoyer Lift usage with a two (2) person assist.

During interviews with Staff S1-S8, were asked if they have been trained on how to use the Hoyer Lift, eight (8) out of eight (8) stated yes, they have had training regarding the Hoyer Lift on Relias, in an In-Service, and directors show you how to use it. Additionally, during interviews with Staff S1-S8, were asked if there have been any issues with a residents’ Hoyer Lift, three (3) out of eight (8) stated there was a reported issue with Resident R1’s Hoyer lift and it was replaced by the hospice agency right away. During interviews with Staff S2 and S3 stated that when they were transferring R1, the lift was not holding R1 and it slowly lowered R1 to the floor. Staff S2 and S3 stated they requested additional assistance and R1 was transferred manually. Staff S2 and S3 stated they reported the incident to the Wellness Director at the time who came and checked the lift and ensured a replacement was sent by the hospice agency.

During interviews with Residents R1-R10, were asked if they have experienced a fall while being assisted with transferring either manually or with a Hoyer Lift, nine (9) out of ten (10) stated no they have not experienced a fall while being assisted with transferring.

During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted with Executive Director, Esperanza Naaktgeboren, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025

LIC9099 (FAS) - (06/04)

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