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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608376
Report Date: 02/06/2026
Date Signed: 02/06/2026 12:57:41 PM

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
01/30/2026 and conducted by Evaluator Bernadette Allen
COMPLAINT CONTROL NUMBER: 11-AS-20260130130622
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:12; 12CENSUS: 11DATE:
02/06/2026
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Area Manager- Irene Formentera TIME COMPLETED:
01:00 PM
ALLEGATION(S):
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9
Staff did not administer medication as prescribed.
INVESTIGATION FINDINGS:
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On 2/6/2026, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegations. LPA identified herself and met with Support Staff Emilita Mina (Emmie) who was informed of the purpose of the visit.

On 2/5/2026, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to investigate and deliver findings for the alleged allegations. LPA identified herself and met with Support Staff Emilita Mina (Emmie) who was informed of the purpose of the visit.

Investigation consisted of the following:
On 2/5/2026 LPA reviewed and obtained Resident Roster dated 12/26/2025 which was updated during the visit with the current residents in care and staff roster dated 1/22/2026, Medication Administration Record (MAR) from 1/1/2026-2/5/2026 and Morphine Record from 7/5/2025 through 2/5/2026, Preplacement appraisal dated 3/14/2024,/RCFE levels of care assessment tool dated 3/14/2024, continued ...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 11-AS-20260130130622
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: 02/06/2026
NARRATIVE
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physicians report dated 3/19/2024, and updated appraisal/needs and services plan dated 1/20/2026 signed on 2/3/2026 electronically.

LPA attempted to interview Staff Member 1 (S1), but they were unavailable. LPA conducted interviews with staff members 2-5 (S2-S5).

On 2/6/2026 At 8:45 AM, LPA was able to conduct an interview with S1.

LPA also interviewed resident 1-2 (R1-R2) and attempted to interview residents 3-9 (R3-R9) during the visit.

Investigation revealed the following:

Allegation 2: Staff did not administer medication as prescribed.


LPA conducted interviews with staff members 1-5(S1–S5) and 5 out of 5 stated residents’ medications are not mismanaged and residents are given their medications as prescribed by their physicians.

Additionally, LPA conducted interviews with residents 1 and 2 (R1–R2) and 2 out of 11 stated that they receive medication daily. When asked who gave their medication, they were both unable to provide details or names of staff members. LPA attempted to interview Residents 3 through 9 (R3–R9); however, they were sleep/unavailable during the visit.

LPA conducted a random review of residents medication administration records (MAR) and obtained documentation for R1. The records revealed that 5 out of 5 files reviewed reflects that the staff are managing residents’ medication and administering medications as prescribed by their physicians.

Based on the interviews, records reviewed and observations the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegation is determined to be Unsubstantiated.

An exit interview was conducted where this report was discussed and provided to Irene Formentera at the conclusion of the visit with appeal rights.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR 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
LIC9099 (FAS) - (06/04)
Page: 2 of 2