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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306004049
Report Date: 04/24/2026
Date Signed: 04/24/2026 10:07:29 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/21/2023 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20230421093912
FACILITY NAME:ROSSMOOR SUNSHINE VILLA-WEMBLEYFACILITY NUMBER:
306004049
ADMINISTRATOR:MARIA D TAVAREZFACILITY TYPE:
740
ADDRESS:11322 WEMBLEY ROADTELEPHONE:
(562) 493-3987
CITY:LOS ALAMITOSSTATE: CAZIP CODE:
90720
CAPACITY:6CENSUS: 4DATE:
04/24/2026
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Mini Resurreccion - Administrator TIME COMPLETED:
10:30 AM
ALLEGATION(S):
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facility did not properly handle resident to avoid skin issues
facility staff did not notify resident’s responsible party of changes in residents condition,
facility staff did not follow resident’s doctor’s orders,
facility staff abandoned resident in the hospital emergency room
facility did not operate within the terms of their license
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility and explained the reason for the visit.
The Department received the complaint on 04/21/2023 and LPA Mendivil conducted the initial visit on 04/28/2023. During the visit LPA Mendivil obtained copies of resident records including physician report and appraisals. LPA Mendivil interviewed staff and attempted to interview residents. Regarding the allegations facility did not properly handle resident to avoid skin issues, facility staff did not notify resident’s responsible party of changes in residents condition, facility staff did not follow resident’s doctor’s orders, facility staff abandoned resident in the hospital emergency room and facility did not operate within the terms of their license the investigation revealed the following:
Resident 1 (R1) was admitted to the facility on March 22nd 2023 following a hospital stay due to left leg wound. Per Administrator (AD) Flormine Resurreccion, AD went to the hospital on March 19th 2023 to assess R1, per AD R1’s leg was wrapped and the wound was not visible during assessment. Per AD home health was arranged for wound care through Care Plus Home Health.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2026
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 5
Control Number 22-AS-20230421093912
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ROSSMOOR SUNSHINE VILLA-WEMBLEY
FACILITY NUMBER: 306004049
VISIT DATE: 04/24/2026
NARRATIVE
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Per AD it was only discovered at a later date that R1’s leg was recommended to be amputated which was also listed on LIC 602 Physician’s Report dated 03/20/2023. Per LIC 602 Physician's Report R1 has a history of skin breakdown “extensively on bilateral upper and lower extremities”.
Per LIC 624 Unusual Incident/Injury Report received on 04/04/2023 for an incident that occurred on 04/02/2023 it was noted that skin tears were observed by staff for R1/ Per LIC 624 AD notified R1’s responsible party and contacted Home Health for a nurse’s assessment. Per report nurse assessed resident and first aid was applied. Based on interviews with 3 out of 3 staff, staff stated they did not mishandle resident causing skin issues. Residents present during LPA Mendivil’s visit on April 28rd, 2023 were not interviewed as they were either asleep or not oriented to time and space.
Per review of LIC 624 submitted to the Department on 04/13/2023 for an incident that occurred on 04/11/2023. Per incident report R1 was sent to UCI hospital due to an unstageable wound and family was contacted after resident was transported using a non-emergent transport.
It was alleged that facility staff did not follow R1’s doctor’s orders. Based on interviews with AD there were contradictory orders from R1's physician and Home Health's physician. Based on interviews with staff, staff stated they follow all physician’s orders and interviews.
It was alleged that the facility abandoned resident in the hospital, Per interview with AD, AD stated she stayed with R1 while in the hospital on 04/11/2023 and was in contact with R1’s family.
It was alleged that the facility did not operate within the terms of their license regarding bedridden residents. Per review of residents’ LIC 602 physician reports, only R1 was listed as bedridden and all other residents were listed as non-ambulatory. Per review of license the facility does have a fire clearance for 1 bedridden resident.
Therefore based on the preponderance of evidence through records reviewed and interviews the allegations facility did not properly handle resident to avoid skin issues, facility staff did not notify resident’s responsible party of changes in residents condition, facility staff did not follow resident’s doctor’s orders, facility staff abandoned resident in the hospital emergency room and facility did not operate within the terms of their license are determined to be unsubstantiated, meaning that although the allegation may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

No deficiencies cited.
An exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2026
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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/21/2023 and conducted by Evaluator Andrea Mendivil
COMPLAINT CONTROL NUMBER: 22-AS-20230421093912

FACILITY NAME:ROSSMOOR SUNSHINE VILLA-WEMBLEYFACILITY NUMBER:
306004049
ADMINISTRATOR:MARIA D TAVAREZFACILITY TYPE:
740
ADDRESS:11322 WEMBLEY ROADTELEPHONE:
(562) 493-3987
CITY:LOS ALAMITOSSTATE: CAZIP CODE:
90720
CAPACITY:6CENSUS: 4DATE:
04/24/2026
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Mini Resurreccion - Administrator TIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Facility staff did not properly assess resident before acceptance into the facility.
INVESTIGATION FINDINGS:
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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced visit to deliver complaint findings. LPA was greeted and granted entry into the facility and explained the reason for the visit.
The Department received the complaint on 04/21/2023 and LPA Mendivil conducted the initial visit on 04/28/2023. During the visit LPA Mendivil obtained copies of resident records including physician report and appraisals. LPA Mendivil interviewed staff and attempted to interview residents. Regarding the allegation facility staff did not properly assess resident before acceptance into the faciltiy, the investigation revealed the following:
Resident 1 (R1) was admitted to the facility on 03/22/2023 following a hospital stay due to left leg wound. Per Administrator (AD) Flormine Resurreccion, AD went to the hospital on 03/19/2023 to assess R1, per AD R1’s leg was wrapped and the wound was not visible during assessment. Per AD home health was arranged for wound care through Care Plus Home Health.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2026
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 22-AS-20230421093912
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ROSSMOOR SUNSHINE VILLA-WEMBLEY
FACILITY NUMBER: 306004049
VISIT DATE: 04/24/2026
NARRATIVE
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Per AD it was only discovered at a later date that R1’s leg was recommended to be amputated which was also listed on LIC 602 Physician’s Report dated 03/20/2023. Per LIC 602 Physician's Report R1 has a history of skin breakdown “extensively on bilateral upper and lower extremities”.

AD stated she visits the resident where they are and conducts an assessment. During interview with AD, AD stated R1's leg wound was wrapped and she did not view the wound until the resident was in the facility. Per AD's interview and a summation of the events AD stated that R1 needed a higher level of care.

Therefore based on the preponderance of evidence through records reviewed the allegation Facility staff did not properly assess resident before acceptance into the facility is determined to be SUBSTANTIATED, meaning the alleged violation occurred.

The following is being cited per California Code of Regulations Title 22 Division 6 Chapter 8. An exit interview was conducted and a copy of this report with appeal rights were provided.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 22-AS-20230421093912
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ROSSMOOR SUNSHINE VILLA-WEMBLEY
FACILITY NUMBER: 306004049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/24/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/06/2026
Section Cited
CCR
87456(a)(3)
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 (a)Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8:(3) Obtain and evaluate a recent medical assessment.
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Administrator stated has implimented a checklist for assesments and has family or responsible party's signature for verification. Administrator stated will create a body check assessment and provide proof to LPA by POC due date.
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This requirement was not met as evidence by
R1's physician report provided information that the faciltiy used to determine R1 needed a higher level of care. This poses a potential 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: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5