Bay Crest Care Center: Broken Doorbell Left Resident Outside - CA
She waited several minutes.
The resident, identified in inspection records only as Resident 1, told a federal inspector on September 3, 2025, that she had tried to ring the doorbell outside the hallway 2 entrance after being dropped off and found it wasn't functioning. She knocked several times before a staff member finally heard her and let her in. She said she was frustrated. She said that if the doorbell had worked, she wouldn't have had to wait outside that long.
Resident 1 has hypertension and congestive heart failure, a condition in which the heart cannot pump blood efficiently and can cause swelling in the legs. Her cognition was documented as intact. She knew exactly what had happened to her and she said so clearly.
The inspector, during a visit the same morning, walked to the hallway 2 door with a licensed vocational nurse. The nurse unlocked the door, pushed the doorbell, and confirmed it didn't work. The nurse said the doorbell was supposed to alert staff when a resident was waiting outside after an appointment. Then the nurse said something that didn't require any elaboration: it's hot outside, and residents could be waiting a long time because no one hears them knocking.
The registered nurse supervisor, interviewed that afternoon, said it was unfair to make residents wait outside. That it could cause them to become impatient and upset.
The Director of Nursing said the same thing in different words. This is their home, she told the inspector. The doorbell should work so they can get back into their home. Not being able to do so could cause them to feel bad, angry, and uncomfortable.
Then came the maintenance director.
He said he was unaware there was a doorbell at the hallway 2 door.
Bay Crest Care Center has three entrance doorbells. One of them, the one outside hallway 2, was broken as of the September 3 inspection. The maintenance director, whose department is responsible under the facility's own written policy for maintaining buildings and equipment in a safe and operable manner at all times, did not know it existed.
The facility's maintenance policy dates to December 2009. It states that maintenance personnel are responsible for keeping the building in good repair and free from hazards. Whether the doorbell had been broken for days or weeks or longer, the inspection report does not say. Nobody interviewed by the inspector offered a timeline. Nobody said when they had last confirmed all three doorbells were working.
Federal inspectors cited the facility for the violation, rating the level of harm as minimal, affecting few residents. The citation is accurate in its narrow sense. One resident waited outside for several minutes. She was not hospitalized. She was not injured in any way the record documents.
But Resident 1 has a heart condition. She had just come back from a medical appointment. She stood outside a locked door in the Torrance heat, knocking, waiting, wondering if anyone inside knew she was there.
The Director of Nursing, to her credit, did not minimize it. This is their home, she said. And she was right. A person should be able to get back into their own home.
Resident 1 told the inspector she was frustrated. That is the word the inspection report uses. It is a modest word for what it describes: a woman with a failing heart, standing outside a door that should have opened for her, knocking into the silence of a building where the person responsible for the doorbell didn't know it was there.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bay Crest Care Center from 2025-09-03 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
BAY CREST CARE CENTER in TORRANCE, CA was cited for violations during a health inspection on September 3, 2025.
She knocked several times before a staff member finally heard her and let her in.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.