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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320341
Report Date: 07/30/2025
Date Signed: 07/30/2025 10:22:41 AM

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
06/02/2025 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20250602144808
FACILITY NAME:PEPPER TREE ASSISTED LIVING IIFACILITY NUMBER:
198320341
ADMINISTRATOR:LUZVIMINDA BASA PARAISOFACILITY TYPE:
740
ADDRESS:24606 PENNSYLVANIA AVENUETELEPHONE:
(310) 947-2165
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY:6CENSUS: 6DATE:
07/30/2025
UNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Anna Leeza DeGuman, CaregiverTIME COMPLETED:
10:22 AM
ALLEGATION(S):
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Staff did not ensure medications were dispensed as prescribed
INVESTIGATION FINDINGS:
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*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 6/6/25.
On 6/6/25 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA Shirley arrived and spoke to the Administrator, Marhlyn Sapugay and the purpose of the visit was discussed. LPA was granted access to the facility.

The investigation consisted of the following:
On 6/6/25 LPA requested and reviewed copies of the following records: Residents file, Resident Roster, Staff roster, Identification and Emergency Contact Information, Physician’s Report, Medication Administration Record, (MAR), emailed communications, responsible party’s text message, Activities Calendar, Administrators Medication Certifications, and Special Incident Report dated 6/6/25. LPA Shirley interviewed Staff 1 – Staff 3 and Resident 1 – Resident 5, R6 was not available for interview. LPA Shirley spoke to a visitor, W1 that was at the facility at the time of investigation.
Con'd on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025
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-20250602144808
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: PEPPER TREE ASSISTED LIVING II
FACILITY NUMBER: 198320341
VISIT DATE: 07/30/2025
NARRATIVE
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The investigation revealed the following:

Allegation: Staff did not ensure medications were dispensed as prescribed

On 6/6/25, LPA Shirley observed R1’s responsible party’s text dated, 5/13/25 sent to S1 regarding the reduction in medication indicated from R1’s doctor. During record review, LPA Felisa Shirley observed an email from R1’s doctor dated 5/13/25, regarding reducing divalproex to every other day for 2 weeks and to discontinue after. Per further review, LPA Shirley reviewed R1’s Medication Administration Record, (MAR), for May 2025 and the record shows that R1 received 500 mg of divalproex 2 times a day, daily from 5/1/25 through 5/31/25. During the course of the investigation, LPA Shirley received a copy of the Special Incident Report dated 6/6/25 stating that there was a medication error that occurred May 19 thru May 30, 2025.

LPA interviewed staff, staff 1 – staff 3 (S-1 – S-3). LPA asked, does staff ensure that medications are dispensed as prescribed. Of those interviewed 3 out of 3 stated yes. LPA interviewed Resident 1 – Resident 5 (R-1 – R-5). LPA asked residents, does staff give you your medications as prescribed. Of those interviewed, 5 out of 5 answered, yes.

Based on observations, information gathered and reviewed, and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be Substantiated.



Based on CCLD staff'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 attached LIC-9099D.

Deficiencies were cited during today's visit.

An exit interview was conducted, and plans of corrections were developed, with Anna Leeza DeGuzman, Caregiver. A copy of this report and appeals rights were provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 11-AS-20250602144808
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: PEPPER TREE ASSISTED LIVING II
FACILITY NUMBER: 198320341
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/20/2025
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care. (4) The licensee shall assist residents with self-administered medications as needed.


This requirement was not met as evidenced by:
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Licensee will submit plan informing the department medication training has been performed with all staff. A written proof of correction must included along with date, time and participants names. Correction must be submitted by due date: 6/20/25 to LPA's email: felisa.shirley@dss.ca.gov or fax attn: to LPA Felisa Shirley to 424-544-1016.

**Corrective action received 6/13/25
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Based on interviews and records reviewed, records revealed that a medication error regarding R1 occurred, 5/19/25 thru 5/30/25 in which the wrong medication was discontinued. This action poses as an immediate health and safety risk to persons 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: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 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
06/02/2025 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20250602144808

FACILITY NAME:PEPPER TREE ASSISTED LIVING IIFACILITY NUMBER:
198320341
ADMINISTRATOR:LUZVIMINDA BASA PARAISOFACILITY TYPE:
740
ADDRESS:24606 PENNSYLVANIA AVENUETELEPHONE:
(310) 947-2165
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY:6CENSUS: 6DATE:
07/30/2025
UNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:Anna Leeza DeGuzman, CaregiverTIME COMPLETED:
10:22 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not ensure planned activities were conducted for residents in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
*This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 6/6/25.
On 6/6/25 Licensing Program Analyst (LPA) Felisa Shirley, conducted an unannounced complaint visit to the address listed above. LPA Shirley arrived and spoke to the Administrator, Marhlyn Sapugay and the purpose of the visit was discussed. LPA was granted access to the facility.

The investigation consisted of the following:
On 6/6/25 LPA requested and reviewed copies of the following records: Residents file, Resident Roster, Staff roster, Identification and Emergency Contact Information, Physician’s Report, Medication Administration Record, (MAR), emailed communications, responsible party’s text message, Activities Calendar, Administrators Medication Certifications, and Special Incident Report dated 6/6/25. LPA Shirley interviewed Staff 1 – Staff 3 and Resident 1 – Resident 5, R6 was not available for interview. LPA Shirley spoke to a visitor, W1 that was at the facility at the time of investigation.
Con'd on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20250602144808
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: PEPPER TREE ASSISTED LIVING II
FACILITY NUMBER: 198320341
VISIT DATE: 07/30/2025
NARRATIVE
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The investigation revealed the following:

Allegation: Staff did not ensure planned activities were conducted for residents in care

On 6/6/25, LPA Shirley observed the activities calendar that was posted on the refrigerator. On 6/6/25, LPA Shirley observed, Dominos, the board game Scrabble and crossword puzzles. LPA observed 2 videos of residents doing chair yoga and exercises. On 6/6/25, LPA Shirley spoke with a visitor, W1 was visiting with a relative at the facility at the time of the investigation. W1 stated that she loved the facility because the staff had a genuine concern for the residents. W1 stated that staff helps the residents celebrate birthdays and different holidays.

LPA interviewed staff, staff 1 – staff 3 (S-1 – S-3). LPA asked, does staff ensure that planned activities are conducted for residents in care. Of those interviewed 3 out of 3 stated yes. LPA interviewed Resident 1 – Resident 5 (R-1 – R-5). LPA asked residents, does staff offer activities for the residents in care to enjoy. Of those interviewed, 5 out of 5 answered, yes.

Based on records review, interviews and observations, LPA did not find sufficient evidence to support the above allegation. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is Unsubstantiated.

No deficiencies were cited for these allegations.

An exit interview was conducted and a copy of this report was provided to Anna Leeza DeGuzman, Caregiver.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5