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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320397
Report Date: 01/21/2026
Date Signed: 01/21/2026 02:28:08 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
01/14/2026 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20260114161425
FACILITY NAME:DIVINE LIFE GUEST HOMEFACILITY NUMBER:
198320397
ADMINISTRATOR:ROSALDO, RODRIGOFACILITY TYPE:
740
ADDRESS:1711 W. 243RD ST.TELEPHONE:
(310) 310-1851
CITY:LOMITASTATE: CAZIP CODE:
90717
CAPACITY:6CENSUS: 5DATE:
01/21/2026
UNANNOUNCEDTIME BEGAN:
09:07 AM
MET WITH:ADMINISTRATOR RODRIGO ROSLDOTIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff hit resident
INVESTIGATION FINDINGS:
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On 01/21/2026 Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Divine Life Guest Home and was greeted by Administrator Rodrigo Rosaldo (S1). LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation.

The investigation consisted of the following: LPA Calderon interviewed Staff S1-S3, residents R1-R4. LPA Calderon obtained the following records: Admission Agreement (dated 07/29/2025). Incident report (dated 07/20/2025), Physician report (dated 05/27/2025), Needs and Service Plan (dated

The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026
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 2
Control Number 11-AS-20260114161425
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: DIVINE LIFE GUEST HOME
FACILITY NUMBER: 198320397
VISIT DATE: 01/21/2026
NARRATIVE
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Regarding the Allegation: Staff hit resident’.

This complaint alleged that the facility staff struck R1 left cheek. LPA Calderon noted staff giving morning medications to residents. LPA Calderon witnessed staff moving residents with no issues and there were no negative interactions between staff and residents. Records review indicate the following: Physician report (dated 05/27/2025) indicates that R1 has health issues and cognitive issues. Interviews indicate the following: S1 indicates that R1 was aggressive with other staff and residents. S1 indicates that R1 refused to take a shower or take R1 medication. 4 out of 4 staff deny the allegation. R1 indicates that unknown male staff member struck R1 right cheek a grabbed R1 right wrist and injured the wrist. R1 indicates that R1 did not call the police and R1 cannot id the attacker. 3 out of 4 residents deny the allegation.

Based on interviews and supporting documentation, the preponderance of evidence standard has NOT been met therefore, the allegation of “staff hit resident” is found to be UNSUBSTANTIATED.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2