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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320118
Report Date: 12/11/2025
Date Signed: 12/11/2025 06:29:40 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
12/03/2025 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20251203105132
FACILITY NAME:PRIME VILLA CLOUDFACILITY NUMBER:
198320118
ADMINISTRATOR:ATENCIO, JOHN PAULFACILITY TYPE:
740
ADDRESS:1009 E MARCELLUS STTELEPHONE:
(562) 473-0620
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:6CENSUS: 5DATE:
12/11/2025
UNANNOUNCEDTIME BEGAN:
09:41 AM
MET WITH:Ruby VidadTIME COMPLETED:
11:59 AM
ALLEGATION(S):
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Staff did not have documentation of resident's medical history to responding emergency medical personnel.
Staff did not timely address a resident's change in medical condition.
INVESTIGATION FINDINGS:
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On December 11, 2025, the California Department of Social Services/Community Care Licensing (CDSS/CCL) Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent unannounced complaint visit. Ruby Vidad, Caregiver greeted the LPA. (LPA) explained that the purpose of the visit is to investigate the allegations mentioned above.

The investigation included a collection of records and a tour of the facility. The Department reviewed several documents, including the Personnel Report LIC 500 (dated 09/17/25), Register of Facility Residents LIC 9020 (dated 05/07/25), and (R1's) Medical Assessment for Residential Care Facilities LIC 602A (dated 07/14/25), Apprisal/Needs and service Plan LIC 625 (dated 09/18/25 & 08/05/23), Medication Adminstration Record (dated 10/01/25), Physician Orders for Life Sustaining Treatment (dated ), Vital Log (dated 10/1/25 -11/28/25) and Oak tree Home Health Records. Interviews conducted with Staff #1-#3 (S1-S3), Residents #2-#3 (R2-R3), and Witness #1-#4 (W1-W4).
(Evaluation Report continues LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
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 5
Control Number 11-AS-20251203105132
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: PRIME VILLA CLOUD
FACILITY NUMBER: 198320118
VISIT DATE: 12/11/2025
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: Staff did not have documentation of resident's medical history to responding emergency medical personnel.

The complaint alleges that the staff did not have documentation of Resident #1's (R1) medical history for the responding emergency medical personnel. Reports indicate attempts were made to obtain paperwork and communicate with the care facility staff regarding the (R1's) condition. However, the staff had no paperwork and did not provide any information about (R1's) health condition or mental status. No additional information was provided.

According to the Identification and Emergency Information (LIC 601) dated May 1, 2023, and the Admission Agreement and Contract dated April 24, 2025, (R1) was admitted to Prim Villa Cloud on May 1, 2025. (R1) began receiving home health services from Oak Tree Home Health, Inc. on September 28, 2025. On November 28, 2025, (R1) was hospitalized at Long Beach Memorial Hospital due to general weakness and labored breathing.

On December 5, 2025, between 10:00 AM and 11:10 AM, the Department interviewed staff members identified as Staff #1 through Staff #3 (S1-S3). Three (3) out of the three (3) could not support this claim. (S1 and S2), who were present when emergency medical personnel were dispatched on November 28, 2025, stated that (R1’s) medical documentation was available for the emergency medical services (EMS). (S1) indicated that (EMS) was provided with (R1’s) service binder, which contained the Medical Assessment for Residential Care Facilities (LIC 602A), the Appraisal/Needs and Services Plan (LIC 625), and the Physician Orders for Life-Sustaining Treatment. However, (EMS) only requested copies of the Identification and Emergency Information form (LIC 601) dated May 1, 2025, and the Medication Record dated October 1, 2025. (S1 and S2) verbally shared (R1's) primary medical diagnoses with (EMS). Upon being informed of (R1’s) condition, (S3) promptly reached out to (R1’s) home health provider and family representative without delay. (S3) emphasized the urgency of the situation by instructing the facility to contact 911 for immediate emergency assistance.

On December 05, 2025, between 10:50 AM and 11:30 AM, the Department interviewed resident members identified as Resident #2 and Resident #3 (R2 and R3).

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
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 5
Control Number 11-AS-20251203105132
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: PRIME VILLA CLOUD
FACILITY NUMBER: 198320118
VISIT DATE: 12/11/2025
NARRATIVE
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Two (2) out of the two (2) resident members were unable to validate this claim. (R2-R3) reported being hospitalized, and hospital or emergency medical services received the necessary documentation to treat them properly. Residents #4 (R4) and #5 (R5) were unable to participate in an interview at this time due to their health conditions.

On December 05, 2025, between 12:30 PM and 01:38 PM, the Department interviewed witness members identified as Witness #1 and Witness #2 (W1-W2). Two (2) out of the two (2) witnesses were unable to confirm this claim. (W1-W2) stated that the facility staff took the necessary steps to ensure immediate emergency assistance for (R1). They also confirmed that the facility has all the required medical documentation EMS needs to obtain during an urgent call.

Resident #1 (R1) was unable to participate in the interview because (R1) passed away before the investigation.

The Department reviewed (R1-R5) service files which included Admissions Agreement, Medical Assessment, Consent Forms, Weight Record, Identification and Emergency Information, Appraisal & Needs Service Plan, Immunization Record, TB Test, Centrally Stored Medication, Safeguards for Property Valuables, and Personal Rights and Physician Orders for Life-Sustaining Treatment (POLST) all to be completed and in order. Further review of (R1’s) Medical Assessment for Residential Care Facilities (LIC 602A dated: July 14, 2025), the Appraisal/Needs and Services Plan (LIC 625 dated September 18, 2025), Medication Administration Record (dated October 1, 2025), Incident Report (LIC 624 dated December 5, 2025), and the Physician Orders for Life-Sustaining Treatment (dated December 28, 2020).

Based on the information gathered, there is insufficient evidence to support the allegation mentioned above.

Allegation #2: Staff did not timely address a resident's change in medical condition.

It is alleged that staff did not respond promptly to Resident #1's (R1) change in medical condition. Reports indicate that a medical assessment of (R1) revealed several abnormal vital signs requiring immediate intervention. This intervention included establishing IV access, administering fluids, providing high-flow oxygen, and delivering a dose of adrenaline. Staff reported that (R1) was last seen behaving normally and without alterations on November 25, 2025. Further reports noted that there was no evidence of physical abuse or trauma on the resident. No additional information regarding this matter was provided.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
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 5
Control Number 11-AS-20251203105132
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: PRIME VILLA CLOUD
FACILITY NUMBER: 198320118
VISIT DATE: 12/11/2025
NARRATIVE
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On December 5, 2025, between 10:00 AM and 11:10 AM, the Department interviewed staff members identified as Staff #1 through Staff #3 (S1-S3). Three (3) out of the three (3) could not support this claim. On November 28, 2025, emergency medical personnel were dispatched, and those present confirmed that (R1) received the appropriate immediate medical attention. (S1) reported to the EMS that on November 25, 2025, during (S1's) duty shift, (R1's) condition appeared normal. However, (S2) and (S3) noted that (R1) had decreased appetite the following day, was not eating much, and had no bowel activity for 2 days, prompting them to notify the home health service. The staff monitored (R1's) intake and output, encouraged fluid intake and mobility, and implemented a clyster for bowl activity. Additionally, vital signs were taken daily, and the staff communicated (R1's) condition to the home health provider. Upon learning of (R1's) situation on November 28, 2025, (S3) immediately contacted (R1's) home health provider and family representative. (S3) stressed the urgency of the situation by instructing the facility to call 911 for immediate emergency assistance.

On December 05, 2025, between 10:50 AM and 11:30 AM, the Department interviewed resident members identified as Resident #2 and Resident #3 (R2 and R3). Two (2) out of the two (2) resident members were unable to support this claim. (R2-R3) the staff are attentive and responsive in seeking medical assistance when there’s a change in condition for a resident in care. Residents #4 (R4) and #5 (R5) were unable to participate in an interview at this time due to their health conditions.

On December 05, 2025, between 12:30 PM and 01:38 PM, the Department interviewed witness members identified as Witness #1 through Witness #4 (W1-W4). Four (4) out of the Four (4) witnesses were unable to validate this claim. (W1-W2) emphasized that the facility staff promptly and effectively secured immediate emergency assistance for (R1). (W2) stated that (R1) was not hospitalized because of negligence, but due to an undetected terminal illness. (W3-W4) affirmed that the staff is exceptionally trained and well-prepared to respond swiftly to any changes in a resident’s condition, ensuring that both medical professionals and family representatives are promptly informed.

Resident #1 (R1) was unable to participate in the interview because (R1) passed away before the investigation.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
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 5
Control Number 11-AS-20251203105132
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: PRIME VILLA CLOUD
FACILITY NUMBER: 198320118
VISIT DATE: 12/11/2025
NARRATIVE
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The Department reviewed (R1’s) service files which included Admissions Agreement, Medical Assessment, Consent Forms, Weight Record, Identification and Emergency Information, Appraisal & Needs Service Plan, Immunization Record, TB Test, Centrally Stored Medication, Safeguards for Property Valuables, and Personal Rights and Physician Orders for Life-Sustaining Treatment (POLST) all to be completed and in order.

Further review of (R1’s) Medical Assessment for Residential Care Facilities (LIC 602A dated: July 14, 2025), the Appraisal/Needs and Services Plan (LIC 625 dated September 18, 2025), Medication Administration Record (dated October 1, 2025), Incident Report (LIC 624 dated December 5, 2025), Vitals Log (dated Oct 1, 2025 – November 28, 2025) and the Physician Orders for Life-Sustaining Treatment (dated December 28, 2020).

Based on the information gathered, there is insufficient evidence to support the allegation mentioned above.

Based on the information collected from the facility inspection, observations, interviews, and records analysis, the Department found no evidence to support the above allegations. The allegations may have happened or are valid, but there is not a preponderance of the evidence to prove that the alleged violations occurred. Therefore, the allegations are Unsubstantiated.


An exit interview was conducted with Ruby Vidad, and copies of the reports were provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
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 5