Bay Crest Care Center in Torrance: Inspection Record Review, Complaints and Abuse Reports (Updated October 30, 2026)

CDPH received a facility-reported incident on November 5, 2025, saying Resident 1 had eloped (left without staff knowledge) the evening before, and made an unannounced visit to investigate. According to the citation, Resident 1 was admitted from a hospital on November 3, 2025, with a recent heart attack, heart failure and chronic obstructive pulmonary disease (COPD). His admission assessment described him as confused, with poor safety judgment.

CDPH found the facility had no system to monitor the front door after 6:30 p.m., when the receptionist was not there. According to the citation, his elopement risk assessment rated him low risk because it said he could not walk or propel a wheelchair, although hospital records, facility records and interviews showed he could walk with minimal help using a front-wheel walker. CDPH found the facility also did not follow its wandering and elopement policy, and inspectors saw an emergency exit alarm ring for eight minutes on November 7, 2025, with no staff response. His medication orders were not entered until November 4, so he missed his scheduled morning medications that day.

According to the citation, Resident 1 left the facility on the evening of November 4, 2025, and was found at a restaurant about one mile away. He complained of shortness of breath, 911 was called, and he was taken to a hospital, where he went into cardiac arrest and was pronounced dead at 11:39 p.m. CDPH issued a Class A citation with a $60,000 penalty, and the related federal survey cited F689 at severity J.

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CDPH received a complaint on October 16, 2025, alleging that a resident burned himself and that staff knew about the burn but did not address it properly. CDPH made an unannounced visit the next day. According to the citation, Resident 1 was a 40-year-old man with paraplegia (loss of movement and feeling in the lower body) and general muscle weakness. His thinking skills were intact.

According to the citation, Resident 1 told inspectors that on October 4, 2025, he cooked eggs in his room with an egg cooker, put four hot eggs in a bowl on his lap and did not feel the heat right away. He later saw his left thigh was red. He waited a couple of days before telling staff. On October 7, staff documented a 5 by 5 centimeter second-degree burn (a burn through the outer layers of skin) on his left thigh, and his physician ordered a burn cream.

CDPH found the facility did not stop Resident 1 from using an unauthorized egg cooker and did not follow its own policy allowing only approved electrical appliances in residents' rooms. Inspectors found multiple staff members knew he had the cooker but did not assess the risk, plan for supervision, address his resistance to room checks, or remove it. A licensed vocational nurse told inspectors she saw the cooker on his floor daily while treating his other wounds and did not tell the director of nursing or the administrator. The director of nursing said he thought the cooker was gone but never checked. CDPH issued a Class A citation with a $25,000 penalty, and the related federal survey cited F689 at severity G.

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CDPH received a complaint on August 14, 2025, about the death of Resident 1 on August 4, 2025, and made an unannounced visit on August 15. According to the citation, Resident 1 had a broken neck, quadriplegia (paralysis from the neck down) and chronic obstructive pulmonary disease (COPD), and was fully dependent on staff. His cognition was intact, and his POLST form (a medical order for end-of-life care) said to attempt CPR if he had no pulse and was not breathing.

CDPH determined that nursing staff did not immediately start basic life support with cardiopulmonary resuscitation (CPR) when Resident 1 was found unresponsive and without a pulse at about 4:50 a.m. on August 4, 2025. According to the citation, CNA 1, who was CPR certified, did not check his pulse, call for help, activate a Code Blue, start CPR or stay with him as the facility's policy required. CDPH found that LVN 1, a licensed vocational nurse, left the room to get her personal blood pressure machine from the medication cart instead of starting CPR right away, which lost time critical to his chance of survival.

According to the citation, 911 was called at 4:57 a.m., seven minutes after he was found, which did not follow the facility's policy to call 911 when a person is unresponsive and not breathing. Paramedics arrived at 5:05 a.m., and the citation lists 5:05 a.m. as the time Resident 1 was pronounced dead. CDPH issued a Class A citation with a $25,000 penalty, and the related federal survey cited F678 at severity J.

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CDPH received a complaint on January 23, 2024, alleging Resident 1 had been denied pain medication for eight days because the facility could not reach her physician, and that her anxiety medication was not being given. CDPH made an unannounced visit on February 6, 2024. According to the citation, Resident 1 was a 77-year-old woman with lung cancer, a Stage III pressure injury (a deep bed sore) on her tailbone, neck disc degeneration, anxiety and generalized body pain. She had a physician's order for oxycodone 10 mg (an opioid pain medication) as needed for moderate to severe pain.

CDPH determined that Resident 1 did not receive her pain medication for seven days. According to the citation, licensed nurses did not order a refill before her oxycodone supply ran out on January 16, 2024, and the pharmacy's refill request was faxed to her physician about 16 hours after the last dose. CDPH found that LVN 1 did not contact the physician to get approval to use oxycodone from the facility's emergency medication kit, and the nurses did not follow the facility's policies on unavailable medications and pain management. Resident 1's physician, who was also the facility's medical director, did not act in a timely way on the pharmacy's refill request.

According to the citation, these failures left Resident 1 with unrelieved severe pain and increased anxiety for seven days, and put her at risk for insomnia, depression and feelings of hopelessness and helplessness. CDPH issued a Class A citation with a $25,000 penalty, and the related federal survey cited F697 at severity G.

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The 2567 report states that inspectors found the facility failed to prevent an unplanned severe weight loss of 22 pounds for Resident 57 between October 14, 2023, and January 5, 2024, equal to 19.6% of his weight in three months. Resident 57 had anemia and severe protein-calorie malnutrition (not getting enough protein and calories). He had severely impaired cognition and depended on staff to eat. His admission weight was 113 pounds.

According to the 2567 report, his nutrition care plan called for one-on-one feeding supervision by staff at every meal and weekly weights. Inspectors found staff did not provide that supervision, did not weigh him weekly, and did not consistently record how much of his meals he ate, including while he was in isolation for COVID-19 from December 9 to December 18, 2023. The registered dietitian did not assess his nutritional needs during the isolation period as facility policy required. The facility also did not hold interdisciplinary team meetings to address his ongoing weight loss.

The 2567 report states that a physician ordered one can of Ensure (a nutrition supplement) three times a day on November 6, 2023. The registered nurse supervisor told inspectors Resident 57 did not receive it because it was not available in the facility from November 6, 2023, to January 11, 2024. During the survey, inspectors saw a family member feeding him lunch and breakfast in bed. The deficiency was cited as F692 at severity G.

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CDPH received a facility-reported incident on June 8, 2023, saying a resident hit a meal tray delivery cart and fell backward, and made an unannounced visit on June 9. According to the citation, Resident 1 was a 70-year-old woman with a pelvic joint injury, lower back pain with sciatica and cancer. Her balance was unsteady and she used a wheelchair, and she told inspectors she was walking with a front-wheel walker back to her room when the cart hit her.

CDPH found the facility failed to deliver meal trays safely. According to the citation, on June 6, 2023, DA 1, a dietary aide, was pushing a metal meal cart around a hallway corner and ran into Resident 1 because the cart, about 6 feet tall, was taller than he was and blocked his view. DA 1 told inspectors he could not see down the hallway to the right or in front of him. Inspectors found no safety mirrors at the hallway corners, and the administrator in training said the facility had no policy on safely moving meal carts.

According to the citation, Resident 1 fell, hitting her back on the floor and her head on the wall. At an acute care hospital she was treated for blunt head trauma and acute compression fractures (bones in the spine that collapse under pressure) of several thoracic and lumbar vertebrae. She had a lumbar kyphoplasty on June 8 and a thoracic kyphoplasty on June 9, 2023 (procedures that inject cement into the spinal bones). CDPH issued a Class A citation with a $25,000 penalty, and the related federal survey cited F689 at severity G.

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CDPH received a complaint on March 20, 2023, alleging that Resident 1 became unresponsive and that a nurse who assessed her did not recognize her change of condition. According to the citation, the complaint stated she was sent to an acute care hospital on September 24, 2022, and died there five days later. CDPH made an unannounced visit on March 21, 2023. Resident 1 was an 81-year-old woman with COPD, congestive heart failure, nerve pain and chronic respiratory failure.

CDPH determined that Resident 1 was receiving several central nervous system depressants (drugs that slow brain activity), including Seroquel, gabapentin and Cymbalta, and was given oxycodone, an opioid, at the same time without a documented indication for pain and without monitoring for opioid side effects such as toxicity and overdose. According to the citation, the facility did not complete her pain assessments as her care plan required, did not tell her physician about a pharmacist's recommendation to give the oxycodone less often, and did not transcribe her oxycodone order accurately when she was admitted from a hospital.

According to the citation, Resident 1 experienced opioid overdoses on September 5, September 9 and September 24, 2022. Each time she was transferred to an acute care hospital and given Narcan (a drug that temporarily reverses an opioid overdose). CDPH found she was not kept free from a significant medication error. CDPH issued a Class A citation with a $25,000 penalty, and the related federal survey cited F757 at severity J.

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