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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608376
Report Date: 02/06/2026
Date Signed: 02/06/2026 01:08:05 PM

Document Has Been Signed on 02/06/2026 01:08 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 HOMEFACILITY NUMBER:
197608376
ADMINISTRATOR/
DIRECTOR:		JEHN MARIC DEMAFELIXFACILITY TYPE:
740
ADDRESS:18312 MANSEL AVENUETELEPHONE:
(310) 371-7193
CITY:REDONDO BEACHSTATE: CAZIP CODE:
90278
CAPACITY: 12CENSUS: 11DATE:
02/06/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:45 PM
MET WITH:Area Manager-Irene FormenteraTIME VISIT/
INSPECTION COMPLETED:
01:26 PM
NARRATIVE
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Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced case management visit. Irene Formentera was informed that, as part of complaint investigation 11-AS-20260130130622 the following observations were made.

LPA observed the following:

The auditory alert device at the front entry was turned on; however, at approximately 10:40 AM, staff member S4 turned the device off, and it was later turned back on at approximately 12:00 PM.

Per the licensee’s care plan and Title 22, Division 6, Chapter 8 – Care of Persons with Dementia, the auditory alert device must remain active at all times. Failure to maintain this device continuously poses a immediate health and safety risk to persons in care. The Area Manager was informed that the auditory alert device should not be used intermittently.

Based on these observations, a citation will be issued for noncompliance with Title 22 regulations on the LIC809-D



An exit interview was conducted, and a copy of the report was provided to Area Manager- Irene Formentera at the conclusion of the visit with appeal rights.
NAME OF LICENSING PROGRAM MANAGER: Stephanie Cifuentes
NAME OF LICENSING PROGRAM ANALYST: Bernadette Allen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 02/06/2026 01:08 PM - It Cannot Be Edited


Created By: Bernadette Allen On 02/06/2026 at 11:55 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: REDONDO BEACH ELDERLY HOME
FACILITY NUMBER: 197608376

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/07/2026
Section Cited
CCR
87705(d)

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 (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions.
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The licensee and area manager have agreed to provide additional training to all staff on the cited regulation to prevent future resident elopements. Proof of completed training with a statement of understanding, signed by all staff members, will be emailed to the Department upon completion.
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This requirement was not met as evidenced by:
Based on LPA observations on February 5, 2026, staff intermittently turned the auditory alert device on and off at the front entry door. Staff were advised that the device must remain activated continuously.
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Bernadette.Allen@dss.ca.gov by the Plan of Correction (POC) due date of February 7,2026.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephanie Cifuentes
NAME OF LICENSING PROGRAM MANAGER:
Bernadette Allen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2026


LIC809 (FAS) - (06/04)
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