Palos Verdes Health Care Center in Lomita: Inspection Record Review, Complaints and Abuse Reports (Updated October 30, 2026)

According to the citation, CDPH received a facility report that on October 1, 2024, Resident 1, a 79-year-old woman, fell backward in her wheelchair while riding in the facility van back from a medical appointment. The records describe her as dependent on staff for transfers.

Inspectors found that Driver 1 put a seat belt across the resident's lap but did not use the four-point straps that anchor a wheelchair to the van floor. CNA 1, who rode along, told inspectors it was her first time escorting a resident, that she was not familiar with the straps and that she did not check them. When the driver made a left turn up a slight slope near the facility, the wheelchair tilted back and the resident's head hit the van lift. Driver 1 told inspectors he realized he had not secured the wheelchair. CDPH also found the facility had not trained CNA 1 well enough on the straps and that staff did not follow the facility's transportation policy.

The citation states Resident 1 was taken to an acute care hospital with a cut and a hematoma (a pocket of clotted blood) on the back of her head, a neck sprain and a right shoulder sprain. The administrator told inspectors he gave staff verbal training on van transport, bought new straps and had staff show they could secure them. CDPH issued a Class A citation with a $25,000 penalty, and the 2567 report lists F689 (accident hazards and supervision) at severity G.

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The 2567 report states that on November 6, 2024, CNA 1 was pulling Resident 1 on a shower chair into Shower Room 1 when the door would not stay open and struck the resident's left foot. According to the report, Resident 1 had Alzheimer's disease and osteoporosis (weak, brittle bones) and needed a lot of help with daily care.

Inspectors found that CNA 1 did not ask anyone to hold the door. CNA 1 told inspectors he had been using his foot to stop the door, that he should have asked for help, and that he told a licensed vocational nurse about the door but did not write it in the maintenance logbook. The licensed vocational nurse told inspectors a door stopper kept the door from opening fully, so staff propped it with their feet, and that she did not see it as broken. The maintenance supervisor told inspectors he had heard about a problem with the door the week before, removed the stopper on November 5, and that someone later put it back. Inspectors found no entry about the door in the maintenance logbook.

According to the report, the resident was sent to an acute care hospital, where the cut on the left big toe was closed with stitches. An X-ray showed a fracture (broken bone) in a small bone of the left fourth toe. Inspectors found the facility also did not follow its own maintenance policy on keeping equipment safe. The facility was cited under F689 (accident hazards and supervision) at severity G.

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The 2567 report states inspectors found the facility did not put 11 residents on enhanced barrier precautions, meaning staff wear a gown and gloves during close care of residents with wounds or devices such as feeding tubes, urinary catheters or a tracheostomy (a breathing opening in the neck). These precautions help stop the spread of multidrug-resistant organisms (germs many antibiotics do not kill). Inspectors saw no signs and no gown-and-glove carts outside these residents' rooms, and saw two therapists and the treatment nurse give care in gloves but no gown. The infection prevention nurse told inspectors the facility had no policy or care plans for these precautions.

According to the report, inspectors declared an immediate jeopardy (a situation likely to cause serious harm) on May 16, 2024. The facility's removal plan placed the 11 residents on precautions, posted signs, set up carts, created a policy and trained staff, and inspectors removed the immediate jeopardy on May 17. The facility was cited under F880 (infection prevention and control) at severity L.

Inspectors also found the facility did not report an injury of unknown source to CDPH within two hours. According to the report, in April 2024 staff found swelling and bruising on the right side of a resident's face, and she was sent to an acute care hospital. A licensed vocational nurse told inspectors she did not tell the director of nursing because the resident said nothing happened. The director of nursing and the administrator told inspectors it should have been investigated and reported. This was cited under F609 (reporting of alleged violations) at severity D.

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According to the citation, Resident 1 was an 86-year-old woman with dementia who did not have the capacity to make decisions and had a history of wandering and hitting and yelling at others. Her care plan called for constant monitoring of her whereabouts. CDPH found she was not given continuous one-to-one monitoring (a staff member always at hand).

The citation states that on August 29, 2023, a CNA found a bump on her forehead, and the cause was not known. On September 5, 2023, at about 4:45 a.m., the maintenance supervisor found her alone in the employee lounge wiping blood from her face. She had a cut on her left eyebrow and was sent to an acute care hospital, where she was treated for a closed head injury and the cut needed three stitches.

The director of nursing told inspectors the resident's one-to-one monitoring stopped after August 15, 2023, "because the facility could not afford it," and that she still wandered, especially at night. Inspectors found gaps in the monitoring log after she returned from the hospital, including no entries for the overnight shifts on September 5 and 6. A CNA told inspectors she was not given a monitoring log when she asked for one. CDPH determined the facility did not follow the resident's care plan or its wandering policy. CDPH issued a Class A citation with a $20,000 penalty, and the 2567 report lists F689 (accident hazards and supervision) at severity G.

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The 2567 report states that on July 24, 2023, Resident 1, who had dementia and a history of wandering and striking out at staff, went into Resident 2's room. Resident 2 told inspectors that Resident 1 began taking clothes from her closet, and when she got out of bed to stop her, Resident 1 knocked her to the ground and hit her. Resident 2 said she yelled for help for at least 20 minutes before a staff member came, and that she felt helpless and feared for her life.

According to the report, Resident 2 was sent to an acute care hospital and treated for contusions (bruises) to her left hand, left elbow and right forearm. An X-ray showed no fracture. Inspectors saw bruises on her left hand and elbow three days later.

Inspectors found the facility did not assess or supervise Resident 1 for wandering and did not have a care plan for her aggressive behavior, refusal of care and wandering. The director of nursing confirmed no wandering assessment was done. Inspectors found staff recorded aggressive behaviors several times in early July, but the physician was not told. The psychologist told inspectors she was never notified of these behaviors and should have been. Inspectors found staff did not follow the facility's abuse, change-of-condition and wandering policies. The facility was cited under F600 (free from abuse and neglect) at severity G.

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According to the citation, CDPH investigated a complaint about staffing in June 2023 and determined the facility had no director of nursing and no registered nurse available. CDPH found the facility did not have a registered nurse working at least eight hours a day, seven days a week, from May 8 to June 5, 2023. Staffing sheets showed days with no registered nurse on any shift, including May 31, June 1 and June 2.

The citation states Resident 1 had infected pressure ulcers (bed sores) on both heels and her hip, infected with MRSA (bacteria resistant to many antibiotics). Her physician ordered the IV antibiotic vancomycin every 48 hours. Inspectors found she did not receive doses due on May 29, May 31 and June 2, 2023. A licensed vocational nurse told inspectors only a registered nurse could give IV medications, that the physician had not been told about the missed doses, and that she did not know what to do. Inspectors found no vancomycin in the facility. The owner told inspectors he fired the director of nursing on May 31.

According to the citation, Resident 1 was sent to an acute care hospital on June 3, 2023, for infected wounds and possible osteomyelitis (bone infection). The 2567 report states the facility hired a registered nurse on June 6 and a director of nursing to start June 8, and inspectors lifted an immediate jeopardy on June 6. CDPH issued a Class A citation with a $25,000 penalty. The 2567 report lists F760 (significant medication errors) at severity J and F727 (registered nurse and director of nursing staffing) at severity L.

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