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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602567
Report Date: 11/13/2025
Date Signed: 11/13/2025 05:03:01 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
12/09/2024 and conducted by Evaluator Elvira Gonzalez
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20241209124307
FACILITY NAME:REGENCY PALMS LONG BEACHFACILITY NUMBER:
198602567
ADMINISTRATOR:KENIA SANCHEZ PADILLAFACILITY TYPE:
740
ADDRESS:117 E 8TH STREETTELEPHONE:
(562) 432-9260
CITY:LONG BEACHSTATE: CAZIP CODE:
90813
CAPACITY:91CENSUS: 74DATE:
11/13/2025
UNANNOUNCEDTIME BEGAN:
02:37 PM
MET WITH:Robert Jackini, Executive DirectorTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not provide adequate supervision to resident in care.
Staff did not report resident's incidents to resident's authorized representative.
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 11/06/25. **

On 11/06/25, the department conducted a subsequent complaint visit to further investigate the above-mentioned allegations and deliver findings. The department met with Robert Jackini, Executive Director, and explained the reason for the visit. The department was granted access to the facility.

The investigation consisted of the following: On 12/10/24, the department requested, reviewed and received the following: a copy of the staff roster, resident roster, Resident Lease Agreement, Service Plan, Resident Assessment, Preplacement Appraisal Information, Identification and Emergency Information, Physician’s Report, Resident Personal Property and Valuables, Admissions Orders, Resident Notes, Resident Care Plan, Unusual Incident/Injury Report for Resident 1(R1), and Staff schedule (dated 11/25/24-11/28/24).
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025
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 6
Control Number 11-AS-20241209124307
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: REGENCY PALMS LONG BEACH
FACILITY NUMBER: 198602567
VISIT DATE: 11/13/2025
NARRATIVE
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Furthermore, the department conducted a tour of the facility and observed the residents to identify any signs of neglect, abuse or other immediate health and safety threats. During the course of the investigation, the following records were also received for R1: Hospice Records from Valley Oaks Hospice, Inc. (dated: 12/01/24-12/16/24) EMS records and 911 recording from Long Beach Fire Department, Death Certificate for R1 from Long Beach Department of Health and Human Services, Home Health Records for R1 from Royal Majesty Home Care, Medical Records from R1’s Gastroenterologist, SoCal Gastroenterology, Hospital Records from St. Mary Medical Center, and Medical Records from Provider 1st R1’s Primary Care Physician, Imaging Records for R1 from St. Mary Medical Center. On 10/15/25, the department requested a copy of the staff roster, resident roster, and the facility menu. The department conducted interviews with witness #1-Witness#15 (W1-W15), staff #1-staff#20 (S1-S20), and residents #2-#7 (R2-R7). The department was unable to interview R1, as R1 passed away on 12/06/24.

The investigation revealed the following:
Allegation: Staff did not provide adequate supervision to resident in care. It is being alleged that R1 sustained injuries resulting from facility neglect. The department reviewed records gathered during the investigation. Physician’s report dated 04/26/23 indicated that R1 is non-ambulatory, confused/disoriented, has sundowning behavior, and needs assistance with activities of daily living (ADLs). Preplacement Appraisal Information Dated 05/04/23 indicated that R1 was ambulatory was able to move in and out of bed or chair; able to move around facility without assistance from another person. It further notes that R1 requires special observation or night supervision due to confusion, forgetfulness, or wandering. Services Plan dated 05/09/23 indicated that R1 needs no assistance with transferring or mobility, but the care team is to monitor for changes in condition and conduct a reappraisal as appropriate. It was also noted that R1 would need ongoing support for disruptive sleep patterns. A review of the Resident Assessment dated 10/10/23 indicates that R1 needs assistance with observation & fall management. Resident’s Annual Assessment Form dated 07/11/24 indicated that staff were to conduct status checks on R1 2-3 times each shift.

The department reviewed Facility body check forms which noted injuries on the following days: 11/07/2024 (bruise and swelling to left hand fingers) and 11/14/2024 (skin tear on left elbow). Facility Endorsement Notes note injuries on the following days: 11/04/2025 (bruising and swelling of left hand) and 11/25/2024 (rash on skin and bruises on left arm.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20241209124307
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: REGENCY PALMS LONG BEACH
FACILITY NUMBER: 198602567
VISIT DATE: 11/13/2025
NARRATIVE
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Communication Log forms indicate that on 11/26/24 at 0536, R1 was found in their bedroom floor by a caregiver, after last being checked at 0300 hours. R1 was observed with two flesh wounds on each elbow and redness to the left side of their temple.

The department received and reviewed Unusual Incident/Injury Report (UIR) dated 11/26/24. Per the incident report, on 11/26/24, at around 0536 hours, R1 sustained an unwitnessed fall. S8 observed R1 on the floor of their room near the sofa with flesh wounds on both elbows and redness to the left side of their head. R1’s sofa, recliner, and laundry basket had been moved and were not in their usual location. S8 notified S9 of the incident, who in turn called 911. R1 was then transported to St. Mary Medical Center.

The department reviewed medical records from St. Mary’s Medical Center Long Beach dated 11/26/24–12/05/24. According to the records, R1 was admitted on 11/26/24 with a diagnosis of blunt head trauma, fracture of left wrist and an intra-ventricular hemorrhage (IVH). R1 was discharged on 12/05/24 with a diagnoses of blunt head trauma, multiple abrasions, and IVH. R1 was admitted to Mom & Dad’s House Cottage Facility and was receiving hospice services from Valley Oaks Hospice.

The department received and reviewed Death Report dated 12/06/24 which stated that R1 died of cardiac arrest on 12/06/2024.

The department conducted interviews with S1-S20. Of those interviewed, 7 out of 20 staff were aware that R1’s motion sensor was turned off or not operable, and 13 out of 20 staff said they did not know if R1’s motion sensor was turned off or not operable. An interview conducted with S1 revealed that at one point they were informed that staff members were turning off the sensors, so an in-service training was provided, and staff was informed not to turn off the sensors. Additionally, S1 confirmed R1’s prior falls in July and October 2023 and acknowledged that such incidents should have triggered a reassessment and care plan update, including checking blood pressure, which was never done. An interview conducted with S4 revealed that caregivers sometimes turned the sensor off to help preserve the batteries when R1 wasn’t in the room. An interview conducted with S5 revealed they would find the sensors off during their morning shift, and that they notified S1 about this issue, and an in service training was provided to all staff.

Continued on LIC9099-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 11-AS-20241209124307
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: REGENCY PALMS LONG BEACH
FACILITY NUMBER: 198602567
VISIT DATE: 11/13/2025
NARRATIVE
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The department conducted interviews with R2-R7, and were unable to interview R1, as they passed away on 12/06/24. Of those interviewed, 6 out 6 residents did not know if anyone had fallen and sustained injuries resulting from facility neglect. 6 out of 6 residents said the facility provides them with the necessary care and supervision.

Based on evidence gathered, interviews 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.

Allegation: Staff did not report resident's incidents to resident's authorized representative. It is being alleged that staff rarely called a resident’s responsible party about incidents including bruises to the residents body. The department interviewed S1-S20, of those interviewed, 3 out of 20 staff corroborated the allegation. Staff added that doctors and family were not notified of R1's injuries or change in condition which included R1's eating habits and ability to ambulate.

On 10/15/25, the department interviewed R2-R7, and were unable to interview R1, as they passed away on 12/06/24. Of those interviewed, 4 out 6 residents said they did not know if staff reported any incidents to their authorized representative, and 2 out of 6 residents said that staff does report any incidents to their authorized representative.

The department conducted an interview with W1. Per W1, R1 had several falls leading up to their fall on 11/26/24. In that time period, facility did not advise them of any changes they would be making to prevent R1 from falling. W1 added that they were not informed of injuries R1 sustained in month on November 2024, they only found out about them because they observed the injuries themselves.

The department conducted a review of records gathered during the investigation. A review of the Resident Assessment dated 10/10/23 indicates that R1 needs assistance with observation & fall management. Resident’s Annual Assessment Form dated 07/11/24 indicated that staff were to conduct status checks on R1 2-3 times each shift.

Continued on LIC9099-C
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20241209124307
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: REGENCY PALMS LONG BEACH
FACILITY NUMBER: 198602567
VISIT DATE: 11/13/2025
NARRATIVE
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The department reviewed Facility body check forms which noted injuries on the following days: 11/07/2024 (bruise and swelling to left hand fingers), 11/12/24 (dry skin on left knee and lower leg, along with bruising to both elbows), and 11/14/2024 (skin tear on left elbow). Facility Endorsement Notes indicate injuries on the following days: 11/04/2025 (bruising and swelling of left hand) and 11/25/2024 (rash on skin and bruises on left arm. Communication Log forms indicate that on 11/04/24, R1 was observed with bruising and swelling to their left hand. On 11/15/24, it was noted that R1 was found in bed with an open skin tear on their left elbow.
The department reviewed an email dated 11/21/24, from R1’s family member to S4 and S13. Email notes that R1’s family member picked up R1 from the facility on 11/20/24 and noticed their elbow was bandaged and their forearm very bruised. R1’s family member asked S4 and S13 if they knew what caused it because two weeks prior, R1’s hand was black and blue and very sore with no explanation. Additionally, R1’s family member said that if it was from a fall, they would need to know because R1’s has anemia and may be light-headed, so they would have to notify R1’s doctor.

Based on evidence gathered, interviews 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.

At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.

An exit interview was conducted, and a copy of this report was provided.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20241209124307
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: REGENCY PALMS LONG BEACH
FACILITY NUMBER: 198602567
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/07/2025
Section Cited
CCR
87468.2(a)(4)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.

This requirement was not met as evidenced by:
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POC cleared on 11/12/25. A staff sign in sheet for an in service training conducted on 11/06/25 titled "ABC's of Senior Living: Always be Considerate" was submitted to the department via email on 11/12/25.
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Based on interviews conducted and record review, the licensee did not comply with section cited above by: On 11/26/24, R1 sustained a fall in their bedroom resulting in wounds to their arms, hands, and a brain bleed. Additionally, staff were aware that R1’s motion sensor was turned off or not operable, which poses a health, safety, and personal rights risks to residents in care.
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Type B
11/20/2025
Section Cited
CCR
87468.1(a)(8)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(8) To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs.

This requirement was not met as evidenced by:
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POC cleared on 11/12/25. A staff sign in sheet for an in service training conducted on 11/06/25 titled "ABC's of Senior Living: Always be Considerate" was submitted to the department via email on 11/12/25.
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Based on interviews conducted and record review, the licensee did not comply with section cited above by: Interview conducted revealed R1’s family was not notified of R1's injuries or change in condition which included R1's eating habits and ability to ambulate, which poses a health, safety, and personal rights risks 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: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6