Mondell Pine Manor I

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Allegation investigated: Resident sustained Stage 3 Pressure injuries while in care. Staff did not ensure resident's diapering needs were properly met.

On 03/05/2026 at approximately 10:30 AM, Licensing Program Analyst (LPA) Angelica Segovia conducted an unannounced subsequent complaint visit. LPA was greeted by staff and stated the reason for their visit. The House Manager, Richard Garcia arrived shortly after to assist with today’s visit. On 05/08/2025 the Woodland Hills South Adult and Senior Regional Office received a complaint alleging the neglect and lack of care from the facility staff resulted in a resident developing pressure injuries. On 5/09/2025, LPA Melissa Spaeth conducted the initial twenty-four (24) hour complaint investigation visit. On 5/12/2025 the complaint was referred to the Community Care Licensing Investigation Branch and accepted as an investigation. The complaint was assigned to Investigator with the California Department of Social Services (CDSS) Laura Garcia (IB). (Continue 9099-C) Substantiated The investigation determined the following: Regarding the allegation: Resident sustained Stage 3 Pressure injuries while in care. It was alleged that Resident 1 (R1) sustained pressure injuries due to the neglect and the lack of care from the facility staff. To investigate the allegation, IB Garcia conducted interviews with three staff members (S1-S3) between the dates of 6/13/2025 to 11/18/2025. IB Garcia’s interview with S1 revealed that staff are required to conduct sponge baths to all residents every day. S1 confirmed that R1 did not have home health or a wound care plan in place. Further interview with S1 revealed that, “…the incident was a lesson for them”. IB Garcia’s interview with S2 revealed that R1’s pressure wounds would emit unpleasant odors along with discoloration, yet they did not seek out any medical assistance for R1’s wound. Additionally, S2 was also unable to provide any body-check logs pertaining to R1. IB Garcia’s interview with S3 revealed that they did not conduct body checks on R1, yet they noticed redness around R1’s pelvic area but did not seek out medical treatment. On 05/09/2025, Special Investigator Assistant (SIA) Amina Luckett subpoenaed R1’s medical records from Palmdale Regional Medical Center. IB Garcia’s record review revealed R1 was admitted on 4/18/2025 where they were examined and the following was observed: a diabetic ulcer to their left heel, a pressure wound to the right lateral ankle measuring, an unstageable pressure wound to the sacrum measuring and moisture-associated skin damage (MASD) to peri wounds. Furthermore, based on IB’s investigation there is enough evidence to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Regarding the allegation: Staff did not ensure resident's diapering needs were properly met. It was alleged that staff did not ensure R1’s diapering needs were properly met. To investigate the allegation, IB Garcia conducted interviews with three staff members (S1-S3) between the dates of 6/13/2025 to 11/18/2025. IB Garcia’s interview with S2 revealed that they failed to check R1 every two hours during their nightshift to see if they required a change in diapering. IB Garcia’s interview with S3 revealed that they would change R1’s diaper when it was “almost leaking” due to R1’s refusal to be changed. Interviews with both S2 and S3 revealed that R1 was capable of requesting when their diaper needed to be changed, however IB Garcia notated that due to R1’s cognitive diagnosis they could not be interviewed. LPA Segovia’s record review on 12/09/2025 of R1’s Physician Report confirmed that R1 had been documented to have cognitive impairments. (Continue to LIC 9099-C) Based on record review and IB’s investigation there is enough evidence to verify the allegation. Therefore, the allegation is SUBSTANTIATED at this time. Citation issued, please refer to LIC 9099-D. Civil penalty assessed. An immediate civil penalty of $500 was assessed today for a violation resulting in an immediate hazard to the health and safety of R1. The House Manager was informed that additional civil penalties might be assessed based on Health and Safety Code 1569.49(f). No other immediate health and safety hazards observed during the time of the visit. Exit interview was conducted, appeal rights were given, and a copy of the report was provided to the House Manager, Richard Garcia Regarding the allegation: Staff did not safeguard resident's personal items. It was alleged that facility staff failed to care for R1’s personal belongings. To investigate the allegation, LPA Segovia attempted interviews with seven (7) residents and four (4) staff members. Per the Reporting Party (RP), three (3) clothing items belonging to R1 were damaged and stained with bleach. LPA’s interview with three (3) residents revealed that staff have not damaged their personal property such as clothing. LPA attempted to interview R1, but they no longer reside at the facility. LPA attempted to interview R5 but due to their inability to validate the questions being asked, LPA terminated the interview. LPA attempted to interview R6 and R7, but they were asleep during LPA’s visit. LPA’s interview with S1 revealed that R1’s damaged clothing was never brought to their attention, nor had they witnessed R1’s clothing to be damaged. LPA’s interview with both S1 and S4 confirmed residents’ clothing are washed everyday with no issues. LPA attempted to interview S2, but they no longer work at the facility. LPA attempted to interview S3, but they were not present during LPA’s visit. During LPA’s physical plant tour, LPA observed residents to be dressed appropriately and well groomed. LPA did not observe any damage to their clothing. LPA observed the laundry appliances to be working and in proper condition. Based on interviews and observations, there is not enough information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time. No other immediate health and safety hazards observed during the time of the visit. Exit interview was conducted, and a copy of the report was provided to the House Manager.the state’s words, verbatim · CDSS document, Mar 5, 2026 · control 31-AS-20250508155156

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87615(a)(1) · Plan of correction due date: Mar 6, 2026

87615 Prohibited Health Conditions. (a) Persons who require health services for or have a health condition including...shall not be...retained in a residential care facility for the elderly:(1) Stage 3 and 4 pressure injuries. This requirement was not met evidence by: Based on IB's investigation, due to the lack and care of facility staff, R1 developed pressure injuries which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 5, 2026

Plan of correction: The Administrator will review the regulation and email LPA Segovia a statement of understanding with current in-service training regarding care of residents to include body check logs for residents by POC due date.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(d) · Plan of correction due date: Mar 6, 2026

87464 Basic Services. (d) A facility need not accept a particular resident for care. However, if a facility chooses to accept a particular resident for care, the facility shall be responsible for meeting the resident's needs... This requirement was not met evidence by: Based on interviews, record review and IB's investigation, facility staff failed to meet R1's needs such as diaper changes which resulted in R1's hospitalizations which poses an immediate Health, Safety, or Personal Rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 5, 2026

Plan of correction: The Administrator will review the regulation and email LPA Segovia a statement of understanding with current in-service training regarding care of residents to include incontinence needs by POC due date.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced visit and was greeted by the facility manager, Richard Garcia. LPA stated the purpose of the visit was to conduct an annual inspection. The staff member confirmed there are three residents living in the facility. The facility is licensed for six (6) non-ambulatory residents of which one can be bedridden. The facility has a hospice care waiver for six residents. LPA Spaeth reviewed the resident records and resident medications at 10:15 am until 11:10 am. LPA reviewed staff files at 11:10 am until 12:00 pm. LPA and the Facility Manager toured the facility at 12:30 until 1:15 pm. Delayed Egress - At 1:02 pm, LPA observed the delayed egress at the sliding glass door that leads to the backyard was not working. The Facility Manager stated the alarm had been turned off earlier today. The Facility Manager turned on the alarm at 1:05 pm. Common Areas – The family room, dining room, and kitchen are combined. The family room is furnished with comfortable seating and a television. The dining room is furnished with a dining room table and chairs. Medications: LPA observed the resident medications, first aid kit, and PPE supplies were safely locked in a hallway closet. Continued on 809-C Kitchen – LPA observed a two day supply of perishable food and a seven day supply of non-perishable food items. The fire extinguisher is located near the kitchen and was operable. The knives are locked in a kitchen drawer. Cleaning solutions are locked underneath the kitchen sink. Laundry Room – The laundry room door has a key-punch lock system. LPA observed the washer/dryer and the laundry detergent were in the room and additional cleaning solutions Garage-Staff Room –The door leading to the garage and the staff room was locked. Resident Rooms: There are three resident rooms which were furnished with a bed, linens, night stand, lamp and chair. The rooms were neat and clean. Bathrooms: There are two bathrooms in the facility. The bathrooms contained hand soap, paper towels, grab bars, and slip resistant mats. LPA observed clean linens. Water Temperature: LPA tested the water temperature at 1:00 pm which was 113 degrees F. Surrounding Grounds: There were no visible hazards, and passageways were free from obstruction. The side gate of the house was closed and was not locked. Comfortable seating is also located in the backyard. Smoke/Carbon monoxide detector: The detector was operable as of 1:10 pm. . Based upon LPA's observations and review of the resident/staff files, the following deficiencies were issued. Exit interview conducted, appeal rights discussed, and a copy of the report was given.the state’s words, verbatim · CDSS document, May 14, 2025

Type of visit: Case Management - Deficiencies

On 5/09/2025, Licensing Program Analyst (LPA) Melissa Spaeth conducted a complaint investigation for Complaint #31-AS-20250508155156. During LPA's visit, LPA observed a staff member who has not been fingerprint cleared. The facility manager confirmed the staff member had been working at the facility for the four past days. The LPA Spaeth spoke to the Licensee, Jerome Viray at 12:45 pm. LPA Spaeth stated to the Administrator the staff member must immediately leave the facility. LPA Spaeth the staff member left the facility 1:00 pm. LPA toured the facility at 1:00 pm until 1:15 pm. LPA observed the delayed egress device to the sliding glass door was not working. LPA observed the facility manager turned on egress device at 1:30 pm. Due to LPA observations, the following deficiencies were issued (see 809-D). Exit interview, appeal rights discussed, and a copy of the report was given.the state’s words, verbatim · CDSS document, May 9, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87761(b) · Plan of correction due date: May 9, 2025

87761 Penalties (b)…an immediate penalty of $100 …per day for a maximum of five (5) days shall be assessed if any individual required to be fingerprinted …has not obtained a California clearance or a criminal record exemption… This is evidenced by: The Licensee failed to ensure a staff member had obtained a California Clearance or a criminal record exemption. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 9, 2025

Plan of correction: LPA Spaeth observed the staff member (S1) left the facility.

From the deficiency page — Deficiency type: Type A · Section cited: CCR88705(k) · Plan of correction due date: May 9, 2025

88705 Care of persons with Dementia (k) The following initial & continuing requirements must be met...to utilize delayed egress devices on exterior doors or perimeter fence gates. This is evidenced by: Based on LPA's observations, the licensee did not comply with the section cited above. LPA observed the delayed egress alarm to the sliding glass door had been turned off. which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 9, 2025

Plan of correction: During LPA's visit, the back door egress device was turned on during the visit

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit and was greeted by the Administrator, Stephanie Domingo. LPA Spaeth stated the purpose of the visit was to complete an annual inspection. The Administrator stated there are no residents living at the facility. During LPA Spaeth's last annual inspection on 11/15/2023, LPA Spaeth toured the facility with the Administrator and did not observe residents in the facility. LPA and the Administrator began the tour of the facility at 10:00 am. LPA observed the three residents' rooms were still furnished with a bed, linens, lamp, night stand, and chair. LPA observed there were no residents in each room. The bathrooms were neat and clean and contained hand soap, paper towels, slip resistant mats and grab bars. LPA observed the common areas such as the dining room and family room still contained comfortable seating. LPA also observed the garage was empty. LPA tested the smoke detector at 10:15 am and observed the detectors were operable. The staff room contained furniture for live-in staff and observed there were no staff members living within the facility. There are no deficiencies to report at this time. Exit interview was conducted and a copy of the report was given to the Administrator.the state’s words, verbatim · CDSS document, Jun 12, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit, knocked on the door, and no one answered. LPA Spaeth called the facility phone and spoke to the Administrator Stephanie Domingo of the Mondell Pine Manor II. The Administrator stated there are no residents living at the facility. The Administrator confirmed there were three residents in which two residents passed away and one moved out three months ago. The Administrator met LPA at 9:30 am. LPA and the Administrator began the tour of the facility at 9:35 am until 10:00 am. LPA observed the three residents' rooms were still furnished with a bed, linens, lamp, night stand, and chair. LPA observed there were no residents in each room. The bathrooms were neat and clean and contained hand soap, paper towels, slip resistant mats and grab bars. LPA observed the common areas such as the dining room and family room still contained comfortable seating. LPA tested the smoke detector at 9:45 am. The staff room contained furniture for live-in staff and observed there were no staff members living within the facility. There are no deficiencies to report at this time. Exit interview was conducted and a copy of the report was given to the Administrator.the state’s words, verbatim · CDSS document, Nov 15, 2023