197608376-5-7-2026-11-AS-SCIS-DU4VUK-20260515164453

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608376
Report Date: 05/07/2026
Date Signed: 05/07/2026 01:59:48 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 HOME		FACILITY NUMBER:	197608376
ADMINISTRATOR:	JEHN MARIC DEMAFELIX		FACILITY TYPE:	740
ADDRESS:	18312 MANSEL AVENUE		TELEPHONE:	(310) 371-7193
CITY:	REDONDO BEACH	STATE: CA	ZIP CODE:	90278
CAPACITY:	12; 12	CENSUS: 9	DATE:	05/07/2026
		UNANNOUNCED	TIME BEGAN:	01:16 PM
MET WITH:	Emilita Mina (Emmie)-Support Staff		TIME COMPLETED:	01:59 PM

ALLEGATION(S):

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9

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

INVESTIGATION FINDINGS:

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**This report supersedes the original report delivered on 2/6/2025. On 5/7/2026, Licensing Program Analyst (LPA) Bernadette Allen arrived at the facility to deliver the corrected 9099 providing clarification on the original report issued on 2/6/2026. **

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 informed of the purpose of the visit.

LPA attempted to interview Residents 1–9 (R1–R9), who were asleep at the time of the visit. However, LPA was able to successfully interview Residents 10–11 (R10–R11).

Continued....

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Bernadette Allen
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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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: 05/07/2026

NARRATIVE

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Investigation revealed the following:

Allegation #1: Staff did not prevent a resident from eloping from the facility.

On 2/6/2026 At 8:45 AM, LPA conducted interviews with staff members, and 3 out of 5 staff stated that R1 did elope from the facility without staff knowledge. The interview with Staff 1 (S1) confirmed that R1 had eloped from the facility without staff’s knowledge and was located at approximately 8:00 AM on the same day.

Interviews with Staff 2–3 (S2–S3) revealed they were not scheduled to work during the incident; however, they reported hearing about R1 eloping from the facility.

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

LPA attempted to interview Residents 1–9 (R1–R9); however, they were asleep during the visit and could not be interviewed. LPA interviewed Resident 10 (R10), who stated they had left the facility but were unable to provide specific details about the incident. Resident 11 (R11) stated they have not left the facility but expressed a desire to return to their home.

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: 05/07/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

LIC9099 (FAS) - (06/04)

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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: 05/07/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/12/2026 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:	1 2 3 4 5 6 7	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.
	8 9 10 11 12 13 14	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.	8 9 10 11 12 13 14	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.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 05/07/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2026

LIC9099 (FAS) - (06/04)

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