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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320305
Report Date: 06/06/2025
Date Signed: 06/06/2025 02:22:47 PM

Substantiated


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
06/04/2025 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250604095253
FACILITY NAME:PALOS VERDES CARE COTTAGEFACILITY NUMBER:
198320305
ADMINISTRATOR:MEDINA, MA. SALVACIONFACILITY TYPE:
740
ADDRESS:1808 PENINSULA VERDE DR.TELEPHONE:
(562) 356-7130
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:6CENSUS: 3DATE:
06/06/2025
UNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Ma Salvacion "Salve" Medina, AdministratorTIME COMPLETED:
02:34 PM
ALLEGATION(S):
1
2
3
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5
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7
8
9
Staff do not ensure the facility's smoke and other detectors are properly operating
Staff do not ensure passageways are free from obstruction
INVESTIGATION FINDINGS:
1
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5
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7
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10
11
12
13
On 06/06/25 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the facility. LPA was met by staff two, Tri Kristianingsih Caregiver (S2), and later by staff one, Ma Salvacion "Salve" Medina (S1) Administrator, and the purpose of the visit was explained. S1 and LPA toured the facility.

The investigation consisted of the following:
On 6/06/25 LPA requested documents, including the resident roster (dated: 06/06/25) and staff roster (dated: 09/01/24), Earthquake/fire emergency drills (last conducted 06/03/25), Emergency and Disaster Plan (LIC610E) (last updated: 04/25/25) and LPA toured the facility. LPA interviewed one (1) out of three (3) residents (R1), one (1) witness (W1) and two (2) out of five (5) staff (S1-S2). Resident two and Resident three (R2-R3) were not able to be interviewed due to their medical condition.

Report continues, see LIC9099-C.
Substantiated
Estimated Days of Completion: 90
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
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-20250604095253
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 CARE COTTAGE
FACILITY NUMBER: 198320305
VISIT DATE: 06/06/2025
NARRATIVE
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The investigation revealed the following:
Regarding the allegation “Staff do not ensure the facility's smoke and other detectors are properly operating”, it is being alleged that the facility’s emergency alert system is in disrepair. During today’s inspection, LPA observed seven (7) smoke/carbon monoxide detectors. LPA observed that three (3) out of seven (7) smoke detectors in the house were in disrepair. From 10:00AM to 11:10AM, LPA interviewed R1, W1, and S1-S2. Interviews revealed the following: S1 and S2 have denied the allegation has taken place, while W1 agreed to have never observed staff testing the smoke alarms. Based on LPA's observation and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited. Please see LIC9099-D.

Regarding the allegation “Staff do not ensure passageways are free from obstruction”, it is being alleged that the outdoor walkways of the facility are obstructed. During today's inspection, LPA observed two (2) outdoor walkways. From 10:00AM to 11:10AM, LPA interviewed R1, W1, and S1-S2. Interviews revealed the following: R1, W1, S1 and S2 have denied the allegation has taken place. S1 has confirmed the Eastern walkway as the main exit. Although nobody interviewed has confirmed the allegation has taken place, LPA's observed one (1) out of two (2) outdoor walkways as being obstructed. Based on LPA's observation, the preponderance of evidence standard has been met. Therefore, the above allegation is found to be Substantiated. California Code of Regulations, Title twenty-two (22), Division six (6) is being cited. Please see LIC9099-D.

There have been two (2) deficiencies cited during today's inspection, please see LIC9099-D.

An exit interview was held with staff one, Ma Salvacion "Salve" Medina (S1), and a copy of the facilities' appeal rights, two (2) deficiencies, and this report have been provided.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 11-AS-20250604095253
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 CARE COTTAGE
FACILITY NUMBER: 198320305
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/06/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/06/2025
Section Cited
CCR
87203
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3
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7
87203 - Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This has not been met as evidenced by:
Based on LPA's observation the licensee did
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2
3
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7
The licensee and LPA have agreed that the facility will ensure that rooms 1, 2 and 3 are able to produce an alarm from the control equiptment observed in disrepair.
During today's visit, S1 repaired rooms 1, 2 and 3 control equiptment. LPA has provided POC letter to S1.
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not ensure the facility remains within the regulations adopted by the State Fire Marshal in rooms 1, 2, 3 to ensure that control equipment produces an alarm signal, and are in working condition, to protect life and property, which poses a potential health risk to residents in care.
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Type B
06/06/2025
Section Cited
CCR
87307(d)(6)
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87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This has not been met as evidenced by:
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The licensee and LPA have agreed that the facility will ensure that all emergency exits will remain free of obstruction.
During today's visit, S1 has cleared the Eastern outdoor walkway. LPA has provided POC letter to S1.
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Based on LPA's observation, the licensee did not ensure that the facilities' Eastern walkway remains free of obstruction, which poses a potential health risk to residents in care.
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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: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
06/04/2025 and conducted by Evaluator Mario Leon
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250604095253

FACILITY NAME:PALOS VERDES CARE COTTAGEFACILITY NUMBER:
198320305
ADMINISTRATOR:MEDINA, MA. SALVACIONFACILITY TYPE:
740
ADDRESS:1808 PENINSULA VERDE DR.TELEPHONE:
(562) 356-7130
CITY:RANCHO PALOS VERDESSTATE: CAZIP CODE:
90275
CAPACITY:6CENSUS: 3DATE:
06/06/2025
UNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Ma Salvacion "Salve" Medina, AdministratorTIME COMPLETED:
02:34 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff do not ensure the facility is in good repair
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 06/06/25 Licensing Program Analyst (LPA) Mario Leon conducted an initial, unannounced, complaint visit at the facility. LPA was met by staff two, Tri Kristianingsih Caregiver (S2), and later by staff one, Ma Salvacion "Salvo" Medina (S1) Administrator, and the purpose of the visit was explained. S1 and LPA toured the facility.

The investigation consisted of the following:
On 6/06/25 LPA requested documents, including the resident and staff roster (dated: 06/06/25), earthquake/fire emergency drills (dated: ) and LPA toured the facility. LPA interviewed one (1) out of three (3) residents (R1), one (1) witness (W1) and two (2) out of five (5) staff (S1-S2). Resident two and Resident three (R2-R3) were not able to be interviewed due to their medical condition.

Report continues, see LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20250604095253
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 CARE COTTAGE
FACILITY NUMBER: 198320305
VISIT DATE: 06/06/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
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The investigation revealed the following:
Regarding the allegation “Staff do not ensure the facility is in good repair”, it is being alleged that the facilities’ aluminum wiring is in disrepair which has resulted in a melted electrical outlet. From 10:00AM to 11:10AM, LPA interviewed R1, W1 and S1-S2. Interviews revealed the following: R1, W1 and S2 have denied the allegation has taken place, while S1 has confirmed that on Tuesday, 06/03/25, maintenance staff have come to replace the outlet due to disrepair, which indicates the facility wishes to provide safe, healthful and comfortable accommodations, furnishings and equipment to residents in care. During today’s inspection, LPA did not observe any of the facilities' lights dimming nor any other electrical concerns and LPA tested the working outlet which charged LPA's laptop computer. Based on LPA's observation 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 this allegation, there have been zero (0) deficiencies cited.

An exit interview was held with staff one, Ma Salvacion "Salve" Medina (S1), and a copy of the facilities' appeal rights, two (2) deficiencies, and this report have been provided.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Mario Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 06/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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