198603222-1-29-2026-28-AS-RORN-DS2TTC-20260310150031

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603222
Report Date: 01/29/2026
Date Signed: 01/29/2026 01:48:13 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/17/2026 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20260117135300

FACILITY NAME:	DISCOVERY COMMONS WHITTIER		FACILITY NUMBER:	198603222
ADMINISTRATOR:	CASTILLO,JOSHUA		FACILITY TYPE:	740
ADDRESS:	12315 BURGESS AVENUE		TELEPHONE:	(562) 777-1477
CITY:	WHITTIER	STATE: CA	ZIP CODE:	90604
CAPACITY:	125	CENSUS: 79	DATE:	01/29/2026
		UNANNOUNCED	TIME BEGAN:	09:43 AM
MET WITH:	Administrator George Gonzalez		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff neglect resulted in resident sustaining an injury due to a fall.
Staff did not ensure resident was adequately hydrated.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 01/29/2026 regarding the above allegations. On 01/22/2026, LPA Ramirez conducted an unannounced initial complaint investigation, and a need further investigation was documented. During today’s visit LPA Ramirez was greeted by Administrator George Gonzalez and explained the purpose of the visit.
The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster, Staff Roster (LIC 500), Staff#1 - 5 interviews (S1 – S5), Attempted Interview of Staff#6-7 (S6-S7), Attempted Interview of Resident#1-5 interviews (R1-R5), Attempted Interview with R1’s responsible party, Copies of Resident#1 (R1): Admissions Agreement, Change in Condition Assessment, Observations Notes on R1, Physician Report and Admissions Orders, Unusual Incident Reports, Hospice Care Orders and Notes and physical plant tour.
SEE 9099-C

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20260117135300

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: DISCOVERY COMMONS WHITTIER	FACILITY NUMBER: 198603222
	VISIT DATE: 01/29/2026

NARRATIVE

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The investigation revealed the following: regarding the allegation “Staff neglect resulted in resident sustaining an injury due to a fall.” It is alleged that staff neglect resulted in a resident sustaining an injury due to a fall. Five (5) out of five (5) staff interviewed denied this allegation. Staff interviews revealed that R1 was considered a high fall risk and staff took interventions to prevent R1’s falls. Staff interviews revealed that R1 was placed on 30-to-45-minute room checks, a fall mat was placed in their room, a wheelchair was used to assist R1, and staff attempted to keep R1 in common areas so that R1 was always in line of sight of staff. Records reviewed revealed that R1 was admitted into the facility on 11/27/2024. On 12/03/2024, R1 was moved into the facility memory care due to a change in condition. Review of Unusual Incident Reports revealed the following: on 06/01/2025, R1 had a witnessed fall and was observed with discoloration to their eye and nose and R1’s responsible party was notified and took to urgent care the same day. On 11/30/2025, R1 had a witnessed fall. R1 was assessed by staff and did not see any visible injuries. Staff contacted R1’s responsible party and R1’s physician regarding the fall. On 12/25/2025, R1 was observed laying on the hallway floor with discoloration to their forehead. Staff called 911 and R1 was sent to a local hospital for further evaluation. R1 was released later that day with no new orders but staff documented R1 was placed on frequent checks as a result of this fall. On 01/15/2026, staff conducted a room check on R1 and discovered R1 on the floor with a minor cut to their forehead. Staff called 911 and R1 was taken to a local hospital for evaluation. R1’s responsible party and physician were notified of R1’s fall. R1 was admitted to the hospital and released back to the facility on 01/16/2026 with hospice care services. Review of R1’s change of condition assessment conducted on 10/26/2025, revealed that R1 was assessed as a high fall risk. LPA Ramirez attempted to interview R1’s responsible party but all attempts were unsuccessful. LPA Ramirez attempted to interview R1 but all attempts were unsuccessful. LPA Ramirez attempted to interview R2-R5 but due to cognitive impairment, responses were unreliable. Record review of R1’s observation notes documented room checks conducted by staff, R1’s falls and notification to R1’s responsible party and physician about the falls. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

SEE 9099-C for continued narrative

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20260117135300

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: DISCOVERY COMMONS WHITTIER	FACILITY NUMBER: 198603222
	VISIT DATE: 01/29/2026

NARRATIVE

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Staff did not ensure resident was adequately hydrated.” It is alleged staff did not ensure R1 was adequately hydrated. Five (5) out of five (5) staff interviewed denied this allegation. Staff interviews revealed that R1 was always provided with water, however, R1 would at times refuse to eat or drink water. Staff interviews revealed that staff would encourage R1 to eat or drink water when R1 would initially refuse but R1 would get agitated if staff persisted. Review of staff observations notes revealed that staff documented R1’s refusal to eat or drink and staff notified R1’s responsible party and physician. LPA Ramirez did observe staffing notes that indicated R1 ate and drank water without resistance. LPA Ramirez attempted to interview R1’s responsible party but all attempts were unsuccessful. LPA Ramirez attempted to interview R1, but all attempts were unsuccessful. LPA Ramirez attempted to interview R2-R5 but due to cognitive impairment, responses were unreliable. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies were cited. Exit interview was conducted. A copy of this report was provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:	DATE: 01/29/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026

LIC9099 (FAS) - (06/04)

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