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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198204399
Report Date: 12/11/2025
Date Signed: 12/11/2025 02:55:20 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
05/15/2024 and conducted by Evaluator Elvira Gonzalez
COMPLAINT CONTROL NUMBER: 11-AS-20240515112718
FACILITY NAME:VILLA REDONDO CARE HOMEFACILITY NUMBER:
198204399
ADMINISTRATOR:MARIA BRAVOFACILITY TYPE:
740
ADDRESS:237 REDONDO AVENUETELEPHONE:
(562) 434-9931
CITY:LONG BEACHSTATE: CAZIP CODE:
90803
CAPACITY:80CENSUS: 49DATE:
12/11/2025
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Jared Mikos, Director of OperationsTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Resident developed multiple pressure injuries while in care resulting in hospitalization.
Resident became extremely dehydrated while in care.
INVESTIGATION FINDINGS:
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On 12/11/25, the department conducted a subsequent visit to further investigate the above allegations and deliver findings. The department met with Director of Operations, Jared Mikos, and explained the reason for the visit. The department was granted access into the facility. The department was later met by Assistant Administrator, Jesus Chavez.

The investigation consisted of the following: On 05/16/24, the department requested a copy of the staff roster, resident roster. The department reviewed service records for residents #1-#7 (R1-R7), and collected copies of the following documents for R1: Admission Record, Admission Agreement, Preplacement Appraisal Information, Resident Assessment Form, Individualized Service Plan, Physician’s Report, Identification and Emergency Information, Consent/Release Forms, Personal Rights, Facility Resident Notes, Outside Agency Documentation.

Continued on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
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 6
Control Number 11-AS-20240515112718
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: VILLA REDONDO CARE HOME
FACILITY NUMBER: 198204399
VISIT DATE: 12/11/2025
NARRATIVE
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Alamitos Belmont Rehabilitation Hospital Order Summary Report (dated: 06/30/2023), Alamitos Belmont Health Care Discharge Summary (dated: 07/07/2023), medical records from Alamitos Belmont Rehabilitation Hospital (dated: 07/07/25), medical records from St. Mary Medical Center-Long Beach, and Home Health Notes from Mission Home Health of Irvine. Additionally, the department conducted a tour of the facility. On 05/29/24, the department conducted interviews with staff #1-#2 (S1-S2). On 06/10/24, the department obtained medical records from Los Alamitos Medical Center (dated: 04/24/24 and 05/10/24). On 06/20/24, the department conducted interviews with residents #2-#4 (R2-R4) and staff #3-#5 (S3-S5). Furthermore, on 12/11/25, the department conducted interviews with staff #6-#7 (S6-S7) and residents #5-#8 (R5-R8).

The investigation revealed the following:
Allegation: Resident developed multiple pressure injuries while in care resulting in hospitalization. It is being alleged that R1 developed multiple pressure injuries while at the facility. During the course of the investigation, the department conducted interviews with S1-S7. Of those interviewed, 4 out 7 staff interviewed acknowledged that R1 developed multiple pressure injuries while in care. An interview conducted with S3 revealed that R1 did not have any pressure injuries when they initially arrived at this facility, and that R1’s pressure wounds got worse in just a few days because they were bed bound. During the course of the investigation, the department conducted interviews with R2-R8. The department was unable to interview R1 as they were no longer at the facility. Of those interviewed, 5 out of 7 residents could not corroborate with the allegation, and 2 out of 7 residents did not provide an answer. 7 out of 7 residents reported that staff check on them frequently.

The department’s review of R1’s Admission Agreement confirms that R1 was admitted and moved into the facility on 07/07/23. The department reviewed Resident Assessment Form (dated: 07/07/23) for R1 and it revealed the following: R1 had no healing wounds or bedsores and had no skin breakdown. R1 is non-ambulatory due to physical impairment and requires an assistive/adaptive devise. R1 had no history of falls. R1 requires one-person transfer assistance. R1 requires status checks routinely, approximately every hour, due to recent hospitalization, change in status, confusion, illness, history of falls, medication change, etc. The department reviewed R1’s Physician’s Report (dated: 07/03/23) and noted the following: R1 is non-ambulatory due to both physical and mental condition and has no history of skin breakdown or condition.
Continued on LIC9099-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20240515112718
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: VILLA REDONDO CARE HOME
FACILITY NUMBER: 198204399
VISIT DATE: 12/11/2025
NARRATIVE
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The department reviewed facility notes (dated: 03/03/24 – 04/29/24) and noted the following: On 03/03/24, R1 was observed with a wound, and home health was called for R1 to receive wound care but there was no answer. On 03/05/24, there was no noted wound on left side of R1’s left foot, and there was some redness noted from R1 constantly leaning on left side. It further notes that R1’s foot is being elevated to prevent further redness or sore forming. On 04/18/24, R1 complained of stomach pain, 911 was called and R1 was sent transported to Long Beach Memorial Hospital. On 04/21/24, R1 returned from the hospital and was observed to have multiple bedsores on lower and upper extremities. It was noted that on 04/23/24, R1’s family was visiting and they noticed that R1’s right foot was swollen. R1’s family requested for R1 to be sent out to the hospital. R1 was taken to Los Alamitos Medical Center. Notes reveal that R1 returned from the hospital on 04/25/24 and will continue receiving care from Mission Home Health. It further notes that R1’s foot appears to be swollen. 04/29/24 staff observed that swelling on R1’s foot had reduced, and it appeared to be no injury to their foot. The department reviewed medical records from Los Alamitos Medical Center (dated: 04/24/24) and noted the following: On 04/24/24, R1 was admitted for swelling of their right foot. Records note that R1 had a stage 1 mild ulcer to the right heel, with no additional pressure ulcers noted at the time. R1 was discharged on 04/25/24 with a diagnosis of swelling of right foot, decubitus ulcer of right heel, stage 1. On 05/03/24, staff spoke with Mission Home Health regarding R1’s pain on their lower back and, also noted that R1 seemed to be in severe pain during changing. On 05/06/241, staff observed R1 had redness on their lower back with some bleeding. A&D was put on R1’s lower back, and Home Health was notified. On 05/10/24, R1 was sent out to Los Alamitos Hospital due to skin tear on their lower back. The department reviewed medical records from Los Alamitos Medical Center (dated: 05/10/24) and noted the following: R1 was admitted on 05/10/24 for pressure ulcers that have progressively worsened. R1 had wounds to their back, right heel, and left leg. Per XR Chest, R1 had Sepsis fever, and on 05/12/24, an infectious disease consult was conducted due to a Urinary Tract Infection (UTI) and sacral decubiti infected sores. R1 had multiple decubitus ulcers with foul smell. R1 was discharged on 05/24/24. The department reviewed Unusual Incident/Injury Report (UIR) (dated: 04/19/24 and 05/16/24). UIR dated 04/19/24 reports that on 04/18/24, R1 complained of severe stomach pain and was transferred to Long Beach Memorial Hospital. UIR notes that R1 returned to the facility from the hospital with bed sores, and no medication changes. It further notes that Mission Home Health will be doing wound care.

Continued on LIC9099-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20240515112718
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: VILLA REDONDO CARE HOME
FACILITY NUMBER: 198204399
VISIT DATE: 12/11/2025
NARRATIVE
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UIR dated 05/16/24 reports that on 05/10/24 R1 was sent to Los Alamitos Medical Center due to pain and suspected infection of wound. It reports that R1 has been receiving wound care from Mission Home Health and that R1’s wound appeared to be worsening. The department reviewed home heath notes from Mission Home Health and they noted the following: Services for R1 began on 07/12/23. On 07/13/23, Mission Home Health conducted a visit with R1 for an initial evaluation and assessment. On 07/21/23, a follow-up visit was conducted and noted that R1 appeared stable in bed. R1 denied any pain or discomfort. Appetite was ok. No significant changes were reported by facility Med-Tech. Taught patient and caregiver on infection control, safety/fall precautions and preventions, and advised to contact doctor for any emergency and/or medical concerns and changes. On 07/26/23, a follow up visit was conducted and no skin breakdown were noted at the time. On 08/08/23, Mission Home Health conducted an evaluation with R1. A new stage 1 pressure ulcer to left heel was noted. Mission Home Health spoke with doctor’s office, and treatment order was obtained. It was noted that R1’s skin was intact throughout, wound care was provided, and caregiver was instructed on repositioning, and pressure offloading. Home Health continued visits on 08/11/23, 08/14/23, 08/24/23, 08/26/23, 08/31/23, and 09/07/23 for stage 1 pressure injury of left heel, which was noted to have worsened during the visit on 09/08/23, 10/05023, and 10/12/23. R1’s left heel got better, then was exasperated. On 10/19/23, Home Health nurse found reddening of lateral malleoli of left ankle and small wound of lateral left foot, which indicated pressure wound. On 10/24/23, stage 1 pressure injury on left ankle noted. On 10/26/23, stage 1 pressure injury noted on 08/08/23 healed. Per Mission Healthcare Home Health notes, it indicated services for R1 momentarily ended on 11/08/23. Services restarted on 03/08/24. Home Health visited from 03/08/24, 03/09/24, 03/19/24, 03/20/24, 04/16/24, and 04/19/24, where it was noted that R1 had no open wounds. Visits restarted on 04/24/24 noting a ruptured blister on edge of let foot and a traumatic superficial wound to right, mid-forearm, no pressure injuries were noted. Visits continued on 04/30/24, 05/04/24 and 05/05/24, noting the following: traumatic superficial wound to right arm had healed, bruise on lateral ankle, scattered bruises on arms, and a ruptured blister on mid edge of left foot. Wound care services ended on 05/08/24.
Based on the information gathered, interviews conducted, and records reviewed, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated.

Continued on LIC9099-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20240515112718
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: VILLA REDONDO CARE HOME
FACILITY NUMBER: 198204399
VISIT DATE: 12/11/2025
NARRATIVE
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Allegation: Resident became extremely dehydrated while in care. It is being alleged that R1 was extremely dehydrated and malnourished, when they went to the hospital, which led to hypoglycemia. On 05/16/24, the department observed water available in the main lobby, and a water dispenser in the second floor.

The department reviewed R1’s Physician’s Report (dated: 07/03/23) and noted the following: R1 is non-ambulatory, with a primary diagnosis of: Alzheimer's Disease, and a secondary diagnosis of: Atrial Fibrillation, Type 2 Diabetes mellitus, Hypertensive, Diabetic Chronic Kidney Disease. On page 3 of the medical records, it notes that R1 has Acute Kidney Injury (AKI) and dehydration. The department reviewed medical records from Los Alamitos Medical Center (dated: 04/24/24) and noted the following: On 04/24/24, R1 was admitted for swelling of their right foot. R1 was discharged on 04/25/24. The department reviewed medical records from Los Alamitos Medical Center (dated: 05/10/24) and noted the following: R1 was admitted on 05/10/24 for pressure ulcers that had worsened. Additionally, records noted that R1 was malnourished and severely dehydrated. R1 was discharged on 05/24/24 with a diagnosis of leg ulcer, heel ulcer, pressure ulcer, Acute Kidney Injury (AKI), Uremia, Rhabdomyolysis, Hypotension, Hypothermia, and Hypoglycemia. Dehydration was not noted on the discharge notes. A review of the facility’s incident reports (March, April, May 2024) did not show an incident involving R1 being hospitalized for dehydration. A review of R1’s Medication Administration Record (MAR) (for the months of March, April, May 2024) noted that R1 was taking Bumetanide 1 MG tablet two times a day, Calcitriol 0.25 MCG capsule three times a week, Hydralazine 25 MG table twice a day with food. A review of medical records from Mission Home Health (dated: 07/12/23 – 05/08/24) and noted the following: Services for R1 began on 07/12/23. A review of the Home Health Certification and Plan of Care report from the medical records from Mission Home Health it notes that R1 had Chronic Kidney Disease, Stage 4.

During the course of the investigation, the department conducted interviews with S1-S7. Of those interviewed, 5 out of 7 staff could not corroborate with the allegation, and 2 out of 5 staff said they did not know of the allegation. 2 out of 7 staff stated fluids are always available in the main lobby, in the second floor, and staff offer, remind, and encourage residents to drink water and other fluids. S6 said the residents receive water with every meal, as needed, and at any time during the day. S6 said that if the residents have other options such as juice, tea, coffee, and that they can always go to the kitchen and ask for it.

Continued on LIC9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20240515112718
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: VILLA REDONDO CARE HOME
FACILITY NUMBER: 198204399
VISIT DATE: 12/11/2025
NARRATIVE
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During the course of the investigation, the department conducted interviews with R2-R8. The department was unable to interview R1 as they were no longer at the facility. Of those interviewed, 7 out of 7 residents could not corroborate with the allegation. 7 out of 7 residents stated there is always water, juice, and coffee available and staff are always asking if they would like something to drink.

Based on the information gathered, interviews conducted, and records reviewed, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated.

An exit interview was conducted with Assistant Administrator, Jesus Chavez, and Director of Operations, Jared Mikos, and a copy of this report, along with appeal rights was provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6