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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 12:47:52 PM

Substantiated


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:
08:30 AM
MET WITH:Area Manager- Irene Formentera TIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff did not prevent a resident from eloping from the facility.
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 allegation. LPA identified herself and met with Support Staff Emilita Mina (Emmie) who was informed of the purpose of the visit. Area manager-Irene Formentera arrived about 10AM and she was inform 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 - 2/5/2026, Preplacement appraisal dated 3/14/2024,RCFE levels of care assessment tool dated 3/14/2024, physicians report dated 3/19/2024, and updated appraisal/needs and services plan dated 1/20/2026 signed on 2/3/2026 electronically for resident 1(R1). LPA attempted to interview Staff member 1 (S1) and conducted interviews with staff members 2-5 (S2-S5).
Substantiated
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 3
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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 LPA also interviewed resident 1-2 (R1-R2) and attempted to interview residents 3-9 (R3-R9) during the visit.
On 2/6/2026 At 8:45 AM, LPA was able to conduct an interview with S1.
Investigation revealed the following:

Allegation: Staff did not prevent a resident from eloping from the facility.

LPA conducted interviews and 3 out of 5 staff members stated R1 did elope from the facility without staff knowledge. The interview with S1 stated R1 had eloped from the facility without staff’s knowledge and located about 8:00AM the same day.

The interviews conducted with Staff 2-3 (S2-S3) stated they were not scheduled to work during the incident but heard about R1 eloping from the facility.

Staff members 4-5 (S4-S5) also stated R1 did elope from the facility on January 16, 2026, at approximately 7:00 AM and was found approximately about 8:00AM the same day.

LPA interviewed Resident 1 (R1), who stated they left the facility but were unable to provide specific details about the incident. Resident 2 (R2) stated they have not left the facility but expressed a desire to return to their home. LPA attempted to interview Residents 3- 9 (R3–R9); however, they were asleep during the visit and could not be interviewed.

Upon arrival, LPA observed that the auditory alert device at the front entry was turned on and approximately about 10:40 AM it was turned off by S4 and later turned back on at approximately about 12:00 PM.

Based on interviews conducted, observations and records reviewed the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC-9099D.

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.

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: 3 of 3
Citations on this Visit Report are Under Appeal!

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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
02/12/2026
Section Cited
CCR
87464(f)(1)
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Basic services shall at a minimum include:
Care and supervision as defined in Section 87101(e)(3) and Health and Safety Code section 1569.2(c).
This requirement was not met as evidenced by:
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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. Manager has also implimented additional auditory devises to R1's bed and door which has been agreed upon with the family. LPA observed at the time of visit.
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Based on interviews conducted on February 5, 2026, and February 6, 2026, at approximately 7:00–8:00 AM, it was determined that R1 eloped from the facility without staff’s knowledge. This incident poses an immediate health, safety, and personal rights risk to persons in care.
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Proof of completed training and statement of understanding signed by all staff members, will be emailed to the Department upon completion.
Bernadette.Allen@dss.ca.gov by the Plan of Correction (POC) due date of February 12, 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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2026
LIC9099 (FAS) - (06/04)
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