Sunnyside Nursing Center in Torrance: Inspection Record Review, Complaints and Abuse Reports (Updated October 30, 2026)

According to the citation, Resident 1 was a 77-year-old woman admitted on 6/20/2026 with diabetes, kidney disease, muscle wasting and dementia. She depended on staff for toileting, bathing and turning in bed, and an assessment on admission scored her at high risk for pressure ulcers (bed sores). CDPH found her baseline care plan listed that risk but had no goals or interventions to prevent pressure ulcers.

CDPH determined she was admitted without pressure ulcers and developed one that was avoidable. Inspectors found a private caregiver hired by her family for companionship was with her about 10 hours a day and gave most of her care, including bathing, transfers, incontinence care, skin checks and repositioning. According to the citation, the facility allowed this without following its policy requiring written approval from the attending physician and the director of nursing for private sitters. CDPH also found staff did not follow facility policies on skin breakdown prevention and on measuring wounds weekly and inspecting them daily.

According to the citation, 10 days after admission she developed a Stage 2 pressure ulcer (a shallow open sore) over the tailbone area, which grew and became unstageable (covered by dead tissue so its depth could not be measured). According to the citation, CDPH classified the violation as Class A, and the penalty was trebled to $75,000. The 2567 report states the facility was cited under F686, treatment and services to prevent and heal pressure ulcers, at severity G.

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According to the citation, Resident 10 was an 81-year-old woman with end stage kidney disease on dialysis, admitted from a hospital on 8/15/2025. Her hospital discharge papers conflicted. One set said not to use baclofen (a muscle relaxant) because it had caused her confusion, while the same papers and a second set said to continue baclofen 5 mg three times a day.

CDPH found that Registered Nurse 1 did not review the full discharge instructions before entering the orders, did not clarify the conflict with her physician, and did not follow the facility's policy requiring nurses to verify hospital orders with the attending physician. Inspectors found the resident received five doses of baclofen from 8/15/2025 through 8/17/2025. According to the citation, on 8/17/2025 she had shortness of breath, a blood pressure of 180/110, weakness, drowsiness and increased confusion, and was sent to a hospital. CDPH states she was diagnosed there with acute toxic encephalopathy (sudden brain dysfunction caused by a toxic substance) and was dialyzed.

According to the citation, CDPH classified the violation as Class A, with a $25,000 penalty. The 2567 report states the facility was cited under F684, quality of care, at severity J, finding the facility failed to keep her from being given baclofen despite its known side effect of confusion.

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According to the citation, Resident 1 was a 63-year-old man admitted on 5/16/2025 for physical and occupational therapy, with kidney cancer, a bone tumor and spinal cord disease. His skin over the tailbone area was intact on admission. A physician ordered on 5/21/2025 that he be turned and repositioned every two hours, and his care plan said the same.

CDPH found staff did not turn and reposition him every two hours as ordered, and the facility's records showed missed repositioning on multiple shifts in May 2025. Inspectors determined staff also did not follow the facility's wound care policy, which called for turning residents who cannot turn on their own and checking them for incontinence every two hours. According to the citation, on 5/27/2025, about 11 days after admission, he had an unstageable pressure injury (a bed sore covered by dead tissue) over the tailbone extending to both buttocks.

According to the citation, the wound was infected and he was sent to an acute care hospital on 6/8/2025, where the dead tissue was removed (debrided) and the wound was reclassified as Stage IV, the most severe stage, reaching muscle, tendon and bone. CDPH found he was then diagnosed with osteomyelitis (a bone infection). According to the citation, CDPH classified the violation as Class A, with a $25,000 penalty. The 2567 report states the facility was cited under F686, treatment and services to prevent and heal pressure ulcers, at severity G.

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According to the citation, on 4/19/2025 Resident 1 took a dowel (a pole used in rehabilitation for shoulder exercises) from the facility's rehabilitation room and used it to hit Resident 3 on her right arm, right shoulder and face, then pushed her to the floor. CDPH found Resident 3 had a fracture of the mid sacrum (the triangular bone at the base of the spine) and was transferred to an acute care hospital on 4/22/2025. The investigation also determined Resident 1 had earlier been accused of hitting another resident, Resident 2, on her left arm with a cane or stick that resembled the dowel.

Inspectors found the facility did not secure the equipment in the rehabilitation room so residents and visitors could not take it without authorization, and Resident 1 got the dowel without staff knowledge or consent. According to the citation, staff did not follow the facility's safety and supervision policy, which calls for the care team to identify accident hazards for individual residents and target interventions to reduce them. CDPH stated these failures placed residents and visitors at risk for serious harm and death.

According to the citation, CDPH classified the violation as Class A, with a $25,000 penalty. The 2567 report states the facility was cited under F600 at severity G, finding the facility did not protect Resident 3 from being struck by Resident 1, and F689, accident hazards and supervision, at severity J. The full narrative of the F689 finding is in the linked report.

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According to the citation, inspectors identified this case during a recertification survey on 2/11/2025. Resident 136 was a 79-year-old woman with osteoporosis (weak, brittle bones) and a history of falls, assessed as high risk for falling. Her care plan called for staff to anticipate and meet her needs. On 12/7/2024 at 11:45 a.m. she was found on the floor in the bathroom doorway, unattended, after she said she fell backward while trying to kick the bathroom door shut.

CDPH found that CNA 2 did not provide supervision in the bathroom to reduce her fall risk, and staff did not follow the facility's fall prevention policy or her fall-risk care plan. According to the citation, on 12/9/2024 she reported hip pain of 10 out of 10 and was sent to an acute care hospital, where she was diagnosed with fractures of multiple pubic rami (bones at the front of the pelvis) and a T12 compression fracture (a collapsed vertebra in the middle back).

According to the citation, CDPH classified the violation as Class A, with a $25,000 penalty. The federal 2567 report for the same survey cited F689, accident hazards and supervision, at severity G. It also cited F686 at severity G for a different resident, Resident 36. The 2567 report states the facility did not give Resident 36 the ordered treatment for a Stage II pressure injury (shallow open sore) from 11/8/2024 to 11/21/2024 or assess the wound weekly, and the wound progressed to Stage IV, exposing deeper tissue.

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The 2567 report states that Resident 1, who was assessed as at risk for wandering, left the facility unsupervised on 10/30/2024 and was missing for over two hours before staff noticed he was gone. According to the report, he had diabetes, and inspectors found his absence placed him at risk of exposure to heat or cold, traffic accidents, blood sugar complications and possible death. He was located on 11/6/2024, eight days after he went missing.

Inspectors found the facility had no system to supervise and monitor his whereabouts, did not develop a care plan addressing his wandering risk, and did not follow its own policy requiring care plans for residents at risk for wandering. The report states that when staff discovered he was missing they called a Code Orange, searched the building and nearby streets, alerted hospitals and shelters, and contacted the sheriff's office.

The 2567 report states the facility was cited under F689, accident hazards and supervision, at severity J. According to the report, inspectors called an immediate jeopardy on 11/6/2024 because nine other residents assessed at risk for elopement could also go missing. The report states the facility submitted a removal plan on 11/7/2024, and the immediate jeopardy was removed that evening after inspectors verified it. The plan included assigning a door monitor to the back entrance starting 10/30/2024 and staff training on the elopement policy on 11/1/2024.

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According to the citation, Resident 1 had paralysis and weakness on her left side, osteoporosis, foot drop and a history of falls, and could not bear weight on her left leg. Her care plan, nursing assessment and Kardex (a care summary used by staff) all called for transfers with a mechanical lift, a device for moving people who cannot stand on their own.

CDPH determined that two certified nursing assistants, CNA 1 and CNA 2, instead tried to move her from her bed to a wheelchair by lifting her under her arms, without the lift. Inspectors found the two CNAs lost control of her, and she slid from the bed and landed on her knees on the floor. According to the citation, she was found with swelling, bruising and an abrasion (a scrape) on her left knee, was later assessed with swelling and fluid buildup in that knee, and was ordered a topical antibiotic for the scrape for 14 days. CDPH also found the nursing staff did not follow the facility's safe lifting and movement policy.

According to the citation, CDPH classified the violation as Class A, with a $25,000 penalty. The 2567 report states the facility was cited under F689, accident hazards and supervision, at severity G, and states she was transferred by two staff who physically lifted her from the bed instead of using the mechanical lift listed in her care plan.

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According to the citation, Resident 5 was a 67-year-old woman with type 2 diabetes who had a stroke, had paralysis on her right side and was fed through a gastrostomy tube (a feeding tube placed in the stomach). She received insulin on a sliding scale based on her blood sugar. CDPH determined her blood sugar checks and insulin were abruptly stopped on 7/6/2023, and her monthly blood tests ordered by her physician were not done.

Inspectors found staff did not follow the facility's lab and diagnostic test policy to arrange those tests, so her blood sugar level in September 2023 was unknown and was not reported to her physician. According to the citation, on 10/1/2023 she had rapid breathing, a rapid heart rate and a blood sugar reading of "Error" because it was above the meter's range. She was sent to an acute care hospital, where her blood sugar was 1199 mg/dl. CDPH found she was admitted to the intensive care unit and had a breathing tube placed because of respiratory failure.

According to the citation, CDPH classified the violation as Class A, with a $25,000 penalty. The 2567 report states the facility was cited under F684, quality of care, at severity G, finding the facility did not keep her blood sugar monitoring and insulin from being abruptly stopped and did not carry out her ordered monthly lab tests.

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