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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 306005743
Report Date: 03/10/2025
Date Signed: 03/10/2025 01:47:38 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
11/26/2024 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20241126160403
FACILITY NAME:ASSURED CARE VILLAFACILITY NUMBER:
306005743
ADMINISTRATOR:DOMPREH-MENSAH, THERESAFACILITY TYPE:
740
ADDRESS:561 EAST SECOND AVETELEPHONE:
(310) 650-4190
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:6CENSUS: 4DATE:
03/10/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Theresa Dompreh-Mensa, AdministratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
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3
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5
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7
8
9
Wrongful eviction
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the allegations listed above. LPA was greeted and granted entry by facility staff after introducing himself and stating the purpose of the visit. Administrator Theresa Dompreh-Mensa was present on the premises.

The initial complaint investigation visit took place on December 5, 2024. LPA accompanied by administrator conducted a tour of the facility's physical plant. There were 5 residents admitted to the facility at the time. LPA requested and reviewed resident records for all five current residents in addition to a resident discharged from the facility in July 2024. Admission agreement and house rules were additionally reviewed along with the visitor's log for the months of October and November 2024. Additional witness interviews were conducted over the course of the investigation.
CONTINUED ON FORM LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
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
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 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
11/26/2024 and conducted by Evaluator Kevin Saborit-Guasch
PUBLIC
COMPLAINT CONTROL NUMBER: 22-AS-20241126160403

FACILITY NAME:ASSURED CARE VILLAFACILITY NUMBER:
306005743
ADMINISTRATOR:DOMPREH-MENSAH, THERESAFACILITY TYPE:
740
ADDRESS:561 EAST SECOND AVETELEPHONE:
(310) 650-4190
CITY:LA HABRASTATE: CAZIP CODE:
90631
CAPACITY:6CENSUS: 4DATE:
03/10/2025
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Theresa Dompreh-Mensa, administratorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff mismanaged resident's medication

Facility staff did not allow visitors during visiting hours
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day, Licensing Program Analyst (LPA) Kevin Saborit-Guasch made an unannounced visit to the facility for the purpose of following up on the investigation of the allegations listed above. LPA was greeted and granted entry by facility staff after introducing himself and stating the purpose of the visit. Administrator Theresa Dompreh-Mensa was present on the premises.

The initial complaint investigation visit took place on December 5, 2024. LPA accompanied by administrator conducted a tour of the facility's physical plant. There were 5 residents admitted to the facility at the time. LPA requested and reviewed resident records for all five current residents in addition to a resident discharged from the facility in June 2024. Admission agreement and house rules were additionally reviewed along with the visitor's log for the months of October and November 2024. Additional witness interviews were conducted over the course of the investigation.
CONTINUED ON FORM LIC9099-C
Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 22-AS-20241126160403
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ASSURED CARE VILLA
FACILITY NUMBER: 306005743
VISIT DATE: 03/10/2025
NARRATIVE
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32
CONTINUED FROM FORM LIC9099-A
During the present visit, LPA conducted additional staff and resident interviews and requested additional records.

Regarding the allegation that Facility staff mismanaged resident's medication, the following has been concluded: Based on interviews conducted and records reviewed, resident R1 was prescribed with a Lorazepam prescription, as needed up to twice a day, by R1's primary care physician. Doses administered were adequately reviewed by staff members and do not appear to evidence any discrepancies between the quantities prescribed and the doses delivered by facility staff. Medication Administration Records reviewed did not evidence any discrepancies either.

Regarding the allegation that Facility staff did not allow visitors during visiting hours, the following has been concluded: Based on interviews as well as a review of the facility's visitor logs for the period of April to July 2024 along with October and November 2024, it was evidenced that all residents, including R1 were able to receive visitors on multiple occasions. Visiting hours, house rules and admission agreements provided confirmed the agreed upon visiting hours. Multiple visitors were additionally witnessed during both inspections.

As a result of the investigation, both allegations are found to be Unfounded, meaning the allegations are false, could not have happened and/or are without a reasonable basis.

An exit interview was conducted with facility staff and a copy of this report was provided at the conclusion of the visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 22-AS-20241126160403
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: ASSURED CARE VILLA
FACILITY NUMBER: 306005743
VISIT DATE: 03/10/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
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14
15
16
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29
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32
CONTINUED FROM LIC9099
During the present visit, LPA conducted additional staff and resident interviews and requested additional records.

Regarding the allegation of Wrongful Eviction, the following has been concluded: Based on interviews conducted and records reviewed, resident R1 was admitted at the facility from Park Regency skilled nursing on May 20, 2024. R1 had a primary diagnosis of a wrist fracture, with additional indications of major depressive disorder and bipolar disorder. Following a reported incident of aggressive behavior towards staff members occurring on June 29, 2024, facility staff called the paramedics and R1 was transferred to St. Jude Hospital and admitted for psychiatric evaluation before eventually being discharged back to a different board-and-care. During the hospitalization, it was stated that hospital staff reached out to facility staff who declined to readmit the resident based on safety concerns. R1's care coordinated agency and responsible party relocated the resident at this time as home care was not an option. R1's responsible party were informed of the safety concerns and licensing staff was stated to have been informed of the situation by the facility's administrator, however no formal 30-day notices or updated reappraisals were conducted by facility staff.

As a result, the allegation is found to be Substantiated, meaning that the he Department obtained sufficient evidence to corroborate the allegation mentioned above. The preponderance of evidence standard has been met. An Advisory Note for Technical Violation is issued on an attached for LIC9102.

An exit interview was conducted with facility staff and a copy of this report was provided at the conclusion of the visit.
SUPERVISORS NAME: Sheila Santos
LICENSING EVALUATOR NAME: Kevin Saborit-Guasch
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4