198201933-4-30-2025-11-AS-UCOL-DJWNX8-20250725105042

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198201933
Report Date: 04/30/2025
Date Signed: 04/30/2025 03:36:08 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
04/22/2025 and conducted by Evaluator Mario Leon

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20250422145802

FACILITY NAME:	PALOS VERDES VILLA LLC		FACILITY NUMBER:	198201933
ADMINISTRATOR:	BIENSTOCK, SETH		FACILITY TYPE:	740
ADDRESS:	29661 S WESTERN AVE		TELEPHONE:	(310) 547-9941
CITY:	RANCHO PALOS VERDES	STATE: CA	ZIP CODE:	90275
CAPACITY:	116	CENSUS: 87	DATE:	04/30/2025
		UNANNOUNCED	TIME BEGAN:	08:51 AM
MET WITH:	Linda Cardenas, Administrator		TIME COMPLETED:	04:37 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility has bed bugs.
Facility has lice.
Staff do not ensure that resident's hygiene needs are being met while in care.
Staff do not ensure that resident's diapering needs are being met while in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 04/30/25 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit. LPA was met by Linda Cardenas, Administrator (S1), and the purpose of the visit was explained. S1 and LPA toured the first floor of the facility.
The investigation consisted of the following:
On 04/30/25 LPA requested and reviewed facility documents, including the following: resident roster (dated: 04/21/25), staff roster (dated 04/21/25) six (6) SIR's (LIC624) (dated from 04/15/25 - 04/19/25), Care logs of residents (dated 04/01/25 - 04/29/25), Palos Verdes Villa 24 Hour (24HR) report (dated 04/01/25 - 04/29/25), AM/PM/Graveyard laundry schedule, Monday-Sunday morning shift shower schedule and eight (8) pest control service reports (dated: 01/02/25 - 04/24/25). LPA interviewed six (6) out of eighty-seven (87) residents and five (5) out of thirty-six (36) staff.
The investigation revealed the following:
Regarding the allegation, “Facility has bed bugs.”. It has been alleged that a resident was observed to have bed bugs, which led to a concern for resident's neglect. On 04/30/25 a wellness check was completed by community care licensing division’s (CCLD) LPA.
Report continues, see LIC9099-C.

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025

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 3

Control Number 11-AS-20250422145802

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: PALOS VERDES VILLA LLC	FACILITY NUMBER: 198201933
	VISIT DATE: 04/30/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Record reviews have revealed that a pest control service conducts semi-monthly visits. The monthly reports have not made any note for the room in question, nor any mention of bedbugs. Between 09:00AM and 10:00AM, LPA checked rooms twelve (RM12), 16 (RM16), 17 (RM17) & 19 (RM19) and no insects were observed to be present within the rooms or on the bed(s). Between 10:00AM & 12:00PM LPA interviewed R1-R5, R6 denied LPA's interview. Five (5) out of five (5) residents (R1-R5) have not agreed the allegation has taken place. Between 12:00PM and 1:00PM, LPA interviewed S1-S5. All five (5) staff (S1-S5) have not agreed the allegation has taken place. Based on record reviews, interviews and observations 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, “Facility has lice.” It has been alleged that a resident was observed to have lice, which led to a concern for resident's neglect. On 04/30/25 a wellness check was completed by community care licensing division’s (CCLD) LPA. Record reviews have revealed that a pest control service conducts semi-monthly visits. The eight (8) monthly reports have not made any note for the room in question, nor any mention of lice. Between 09:00AM and 10:00AM, LPA checked rooms twelve (RM12), 16 (RM16), 17 (RM17) & 19 (RM19) and no insects were observed to be present within the rooms or on the bed(s). Between 10:00AM & 12:00PM LPA interviewed R1-R5, R6 denied LPA's interview. Five (5) out of five (5) residents (R1-R5) have not agreed the allegation has taken place. Between 12:00PM and 1:00PM, LPA interviewed S1-S5. All five (5) staff (S1-S5) have not agreed that the allegation has taken place. Based on record reviews, interviews and observation 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 ensure that resident's hygiene needs are being met while in care.”. It has been alleged that residents were not provided a suitable hygiene plan. Record reviews have revealed that the facility follows a Monday-Sunday morning shift shower schedule, noting the resident in question is marked to receive a shower three times (3x) per week (/week). Care logs of residents have revealed that the resident in question receives a shower 3x/week. Between 10:00AM & 12:00PM LPA interviewed R1-R5, R6 denied LPA's interview. Four (4) out of five (5) residents (R1-R4) have not agreed that the allegation has taken place. Between 12:00PM and 1:00PM, LPA interviewed S1-S5. All five (5) staff (S1-S5) have not agreed the allegation has taken place.

Report continues, see LIC9099-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20250422145802

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: PALOS VERDES VILLA LLC	FACILITY NUMBER: 198201933
	VISIT DATE: 04/30/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

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 ensure that resident's diapering needs are being met while in care.”. It has been alleged that residents were not provided an incontinence plan. Record reviews have revealed that the facilities' Care logs of residents (dated 04/01/25 - 04/29/25) have displayed the resident in question to have received incontinence checks within a two-hour interval. Between 10:00AM & 12:00PM LPA interviewed R1-R5, R6 denied LPA's interview. Four (4) out of five (5) residents (R1-R4) have not agreed that the allegation has taken place. Between 12:00PM and 1:00PM, LPA interviewed S1-S5. All five (5) staff (S1-S5) have not agreed 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.

There has been zero deficiencies cited during today’s visit.

An exit interview was held with staff one, Linda Cardenas (S1) Administrator, and a copy of this report has been provided.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:	DATE: 04/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/30/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3