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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608376
Report Date: 11/05/2025
Date Signed: 11/05/2025 10:46:13 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/03/2025 and conducted by Evaluator Regina Cloyd
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250903081823
FACILITY NAME:REDONDO BEACH ELDERLY HOMEFACILITY NUMBER:
197608376
ADMINISTRATOR:JEHN MARIC DEMAFELIXFACILITY TYPE:
740
ADDRESS:18312 MANSEL AVENUETELEPHONE:
(310) 371-7193
CITY:REDONDO BEACHSTATE: CAZIP CODE:
90278
CAPACITY:12CENSUS: 8DATE:
11/05/2025
UNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Irene FormenteraTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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9
Staff did not inform responsible party of resident's change of condition.
INVESTIGATION FINDINGS:
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On 11/05/25, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent visit to deliver findings regarding the above allegation. LPA met with Staff and spoke with Area Manager Irene Formentera over the phone and the purpose of the visit was explained.

Investigation consisted of the following: On 09/04/2025, LPA obtained Personnel Report (dated 07/01/25), Staff Schedule (07/27/25 – 08/02/25), eight Staff Training Records, Register of Residents (08/29/25), R1’s Providence 602, Medication List, X-Ray (07/03/25), Identification and Emergency Information (07/07/25), Preplacement Appraisal Information (07/07/27), Admission Agreement (pages 4 and 47 of 47), July 2025 – August 2025 Medication Administration Record, Providence Plan of Care Medication Profile (08/04/25 – 08/05/25) and Multidisciplinary Field Notes (08/04/25 - 08/05/25), Visitor Sign-In Sheet (07/31/25 – 08/08/25), and Visitor Sign-In Sheet (07/31/25 – 08/08/25), Medication Destruction Record (08/05/25). LPA interviewed Staff #1 – 4. On 09/11/25, LPA interviewed Staff #5 – 7. On 09/17/25, LPA interviewed Staff #8 and Witness #3 - #4, and #7. Continue to LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 11-AS-20250903081823
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: REDONDO BEACH ELDERLY HOME
FACILITY NUMBER: 197608376
VISIT DATE: 11/05/2025
NARRATIVE
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On 10/01/25, LPA retrieved a copy of R1’s Morphine Record (08/04/25), Physician’s Reports (R2 – R6), Updated Training Record (S1) and interviewed Witnesses #1 - #2. On 10/13/25, LPA received R1’s records from Home Care Visit in Providence Hospice LA County. On 10/16/25, LPA interviewed Witness #11. On 10/17/25, LPA interviewed Witness #5, #7, #9 and #10. On 10/30/25, LPA received R1’s death certificate. On 11/03/25, LPA interviewed Staff #9 - #10. Note: LPA left a message/voicemail to interview Witness #6, #8 (09/17/25, 09/29/25, 10/17/25).

Regarding the allegation, “Staff did not inform responsible party of resident's change of condition,” it is being alleged that R1 collapsed on 07/29/25 and the responsible parties were not notified. Record review of Home Care Visit in Providence Hospice LA County (Encounter Notes) revealed on 07/29/25, R1 lost consciousness after dinner, per B&C caregiver. R1 was taken to his bed, however, R1’s health continued to decline and R1 became unresponsive and bedbound since 08/01/25. Record review of staff schedule (07/29/25) revealed that S7 worked from 3 PM - 12 AM, S3 worked from 6 AM - 6 PM, S8 worked from 11 AM - 8 PM, S1 worked from 7 AM - 4 PM, and S6 worked from 12 AM - 9 AM. Interview with Hospice Nurse (Witness 11) indicated W11 was unable to recall the name of the B&C caregiver but indicated that the staff was a woman (S1, S3, S6 - S7). Five out of five staff interviews (S1, S3 and S6-S8) indicated R1 did not collapse nor fall. Interview with the Administrator indicated that there were no reports of R1 collapsing. S7 indicated that R1 did not collapse but during dinner, S7 noticed R1 was getting tired so R1 was assisted to R1’s room. Four out of six responsible party/witness interviews (W4 – W7, W9 - W10) indicated they are notified of incidents and changes of resident’s condition.

Regarding the allegation, “Staff did not inform responsible party of resident's change of condition,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.

An exit interview was conducted over the phone with Area Manager Irene Formentera and a copy of this report was provide to Staff.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2