197608376-5-7-2026-11-AS-SCIS-DU4VUL-20260515164454

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608376
Report Date: 05/07/2026
Date Signed: 05/07/2026 02:03:36 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 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:	02:20 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not administer medication as prescribed.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

**This report supersedes the original report delivered on 2/6/2025. On 5/7/2026, Licensing Pogram 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 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.

Continued

Unsubstantiated

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)

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: 05/07/2026

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

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, physicians report dated 3/19/2024, and updated appraisal/needs and services plan dated 1/20/2026 signed on 2/3/2026 electronically. As well as an random review of residents’ medication administration records (MAR)

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 daily.

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) who stated they receive medication daily. When asked who gave their medication, they were both unable to provide details or names of staff members.
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: 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)

Page: 2 of 2