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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602406
Report Date: 09/18/2025
Date Signed: 09/29/2025 01:01:16 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/08/2025 and conducted by Evaluator Pamela Bunker
COMPLAINT CONTROL NUMBER: 11-AS-20250708131300
FACILITY NAME:ALABASTER ELDERLY CAREFACILITY NUMBER:
198602406
ADMINISTRATOR:DAVIS, DELORESFACILITY TYPE:
740
ADDRESS:9825 8TH AVENUETELEPHONE:
(323) 971-2964
CITY:INGLEWOODSTATE: CAZIP CODE:
90305
CAPACITY:6CENSUS: 6DATE:
09/18/2025
UNANNOUNCEDTIME BEGAN:
08:18 AM
MET WITH:Delores DavisTIME COMPLETED:
11:25 AM
ALLEGATION(S):
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Staff did not provide a refund upon resident’s death
INVESTIGATION FINDINGS:
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*** The purpose of the visit is to add additional information not included in the report dated 07/18/2025; findings remain the same.***

On 09/18/2025, at 8:18 a.m., the California Department of Social Services Community Care Licensing Division (CDSS/CCLD) Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced subsequent visit to gather information regarding the above allegations. LPA Bunker met with Delores Davis, Licensee, and explained the purpose of the visit. LPA was granted entry into the facility.

The investigation consisted of the following: On 07/18/2025 at 12:30 p.m., LPA Bunker reviewed and obtained copies of resident 1's records, Resident Roster (Dated 07/01/2025), Admission Agreement (Dated 11/06/2024), Identification and Emergency Information (Dated 11/06/2024), Physician’s Report (Dated 11/06/2024), Appraisal & Needs and Services Plan (Dated 11/06/2024),
See continued LIC9099-C Page #2
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
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 4
Control Number 11-AS-20250708131300
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ALABASTER ELDERLY CARE
FACILITY NUMBER: 198602406
VISIT DATE: 09/18/2025
NARRATIVE
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Continued LIC9099-C page #2

Functional Capability Assessment (Dated 11/06/2024), Preplacement Appraisal Information (Dated 11/06/2024), Consent Form (Dated 11/06/2024), Personal Rights (Dated 11/06/2024), Safeguards for Cash Resources (Dated 11/06/2024), Safeguards for Property/Valuables (Dated 11/06/2024), Death Report (Dated 12/17/2024). The Department conducted interviews with the Staff Member #1 (S1) and Witnesses #1 and #2 (W1-W2).

Investigation Reveals the following:

Allegation: Staff did not provide a refund upon the resident’s death.
It was alleged that Resident 1 (R1)'s room and board were paid for the entire month of December 2024, and staff did not issue a refund upon the resident’s death.

At 2:00 p.m., Staff Member #1 (S1) was interviewed and reported that R1 moved into the facility on November 06, 2024, and passed away on December 12, 2024. On December 17, 2025, S1 submitted a copy of the death report to Community Care Licensing regarding R1's passing.

R1's Admission Agreement on Refund Conditions/Resident Death, dated November 06, 2024, was reviewed. It states that the facility will refund any fees paid in advance covering the time after the resident's personal property has been removed from the facility within 15 days.

One out of one staff member agreed that R1 was owed $3,065.00, which has not been refunded after R1's death and the removal of their belongings. S1 confirmed that, as of today, no payment has been made.

On 07/18/2025, the Department interviewed Witnesses #1 and #2 (W1-W2), who stated that Resident #1 (R1) lived at the facility and passed away on 12/12/2024. W1 and W2 reported that they paid for the entire month of December 2024 and have both spoken to Staff Member 1 (S1) regarding the refund they are owed. W1 and W2 stated that S1 requested that payment arrangements could be made in monthly installments; however, no payments have been made.

See continued LIC9099-C page 3
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20250708131300
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: ALABASTER ELDERLY CARE
FACILITY NUMBER: 198602406
VISIT DATE: 09/18/2025
NARRATIVE
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Continued LIC9099-C page 3

Based on LPA’s observations, interviews that were conducted, and records reviewed, the preponderance of evidence standard has been met; therefore, the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC9099-D.

Appeal rights were discussed, and copies of the Complaint Investigation Report LIC 9099 and LIC9099-C were provided to Licensee Delores Davis. Exit interview conducted.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20250708131300
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: ALABASTER ELDERLY CARE
FACILITY NUMBER: 198602406
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/05/2025
Section Cited
HSC
1569.652(c)
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Health and Safety Code section 1569.652 (c): A refund of any fees paid in advance covering the time after the resident’s personal property has been removed from the facility shall be issued to the individual, individuals, or entity contractually responsible for the fees or,
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The licensee agrees to a payment plan and will refund the $3,065.00 in fees by the POC due date of 10/05/2025.
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if the deceased resident paid the fees, to the resident’s estate, within 15 days after the personal property is removed.
This requirement was not met as evidenced by: The licensee failed to refund fees paid in advance. This poses a potential 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: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Pamela Bunker
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4