197608376-1-31-2025-11-AS-RCLD-DDFTWH-20250131140532

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608376
Report Date: 01/31/2025
Date Signed: 01/31/2025 02:06:23 PM

Document Has Been Signed on 01/31/2025 02:06 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	REDONDO BEACH ELDERLY HOME		FACILITY NUMBER:	197608376
ADMINISTRATOR/ DIRECTOR:	JEHN MARIC DEMAFELIX		FACILITY TYPE:	740
ADDRESS:	18312 MANSEL AVENUE		TELEPHONE:	(310) 371-7193
CITY:	REDONDO BEACH	STATE: CA	ZIP CODE:	90278
CAPACITY: 12		CENSUS: 11	DATE:	01/31/2025
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:09 AM
MET WITH:	Irene Formentera		TIME VISIT/ INSPECTION COMPLETED:	02:15 PM

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

On 01/31/2025, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced – annual continuation inspection and met with Staff. The Area Manager Irene Formentera arrived later.

Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

First Aid kit was available. Two fire extinguishers, last serviced August 6, 2024 was observed in the living room and in the hallway between rooms #1 and #2. Area Manager tested the carbon monoxide detector and smoke detectors in the house. Both devices were functional.

Five staff records were reviewed, 5 out of 5 staff records had current first aid certificates and required criminal record clearances or criminal record exemptions.

On 01/30/25, six resident records were reviewed and, six out of six resident records had medical assessments and pre-appraisal or reappraisals. Two residents’ medication was reviewed. On 01/31/2025, four more medical assessments and pre-appraisal were reviewed.

Continue to LIC809-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

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

LIC809 (FAS) - (06/04)

Page: 1 of 3

Document Has Been Signed on 01/31/2025 02:06 PM - It Cannot Be Edited

Created By: Regina Cloyd On 01/31/2025 at 01:30 PM

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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: REDONDO BEACH ELDERLY HOME	FACILITY NUMBER: 197608376
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/31/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87606(c)

Care of Bedridden Residents

(c) To accept or retain a person who is bedridden, other than for a temporary illness or recovery from surgery, a licensee shall obtain and maintain an appropriate fire clearance as specified in Section 87202, Fire Clearance. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above for one resident which poses an immediate safety risk to persons in care. Resident #5 has a bedridden status and currently resides in room #5. The room has not been approved for bedridden residents.
	POC Due Date: 02/01/2025
	Plan of Correction
1 2 3 4	The Licensee will relocate resident #5 into a bedridden room by the POC due date and email evidence to regina.cloyd@dss.ca.gov. The Licensee will ensure that bedridden residents only reside in approved bedridden rooms (1, 2, and 9).

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Ulysses Coronel

LICENSING EVALUATOR NAME:

Regina Cloyd

LICENSING EVALUATOR SIGNATURE:

DATE: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: REDONDO BEACH ELDERLY HOME	FACILITY NUMBER: 197608376
	VISIT DATE: 01/31/2025

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

Deficiencies are being cited based on LPA's observation and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. Resident #5’s (R5) medical assessment reveals a bedridden status. However, R5 is currently in room #5 and it is not approved for bedridden residents. This violation warrants an immediate civil penalty of $500.00 and is hereby assessed, see LIC421IM.

An exit interview was conducted, technical assistance provide, Plan of Correction was developed, and a copy of this report and appeals was discussed and left with Area Manager Irene Formentera.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3