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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608376
Report Date: 10/01/2025
Date Signed: 10/01/2025 05:02:40 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
09/03/2025 and conducted by Evaluator Regina Cloyd
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250903081823
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:12CENSUS: 8DATE:
10/01/2025
UNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH: Irene FormenteraTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff not qualified to give medication.
INVESTIGATION FINDINGS:
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On 10/01/2025, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent visit to gather information regarding the above allegation. LPA met with Staff and Area Manager Irene Formentera and the purpose of the visit was explained.

Investigation consisted of the following: On 09/04/2025, LPA obtained Personnel Report (dated 07/01/25), Staff Schedule (07/27/25 – 08/02/25), eight Staff Training Records, Register of Residents (08/29/25), R1’s Providence 602, Medication List, X-Ray (07/03/25), Identification and Emergency Information (07/07/25), Preplacement Appraisal Information (07/07/27), Admission Agreement (pages 4 and 47 of 47), July 2025 – August 2025 Medication Administration Record, Providence Plan of Care Medication Profile (08/04/25 – 08/05/25), Multidisciplinary Field Notes (08/04/25 - 08/05/25), Visitor Sign-In Sheet (07/31/25 – 08/08/25), and Medication Destruction Record (08/05/25). LPA interviewed Staff #1 – 4. On 09/11/25, LPA interviewed Staff #5 – 7. On 09/17/25, LPA interviewed Staff #8 and Witness #3 - #4, and #7. Continue to LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
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 8
Control Number 11-AS-20250903081823
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: 10/01/2025
NARRATIVE
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 On 10/01/25, LPA retrieved a copy of R1’s Morphine Record (08/04/25), Physician’s Reports (R2 – R6), Updated Training Record (S1) and interviewed Witnesses #1 - #2. Note: LPA left a message/voicemail to interview Witness #5 - # 6, #8 (09/17/25, 09/29/25), and Witness #9 - #10 (09/29/25).

Investigation revealed the following:

Allegation: Staff not qualified to give medication.

Regarding the allegation, “Staff not qualified to give medication,” it is being alleged that Staff #1 was not qualified to administer R1’s medication. Record review of personnel policies revealed that each employee is required to have continuous training and applicable certificates in hospice care and proper handling of medication and required documentation. Medications’ policy and procedure revealed that two hours of hands-on-shadowing training will be provided prior to assisting with the self-administration of medication. Record review of staff training revealed S1 has zero (0) medication training in 2024 and three hours of medication training in 2025. Record review of hospice medication administration record revealed S1 administered R1’s medication on 08/05/25 10:30 AM.

Regarding the allegation, “Staff not qualified to give medication,” based on record reviews and interviews, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. Health and Safety Code, Title 22, Division (6) and Chapter (03.2) are being cited on the attached LIC 9099D.

An exit interview was conducted, plans of correction developed, and a copy of this report with appeal rights were provided to the Area Manager Irene Formentera.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 8
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
09/03/2025 and conducted by Evaluator Regina Cloyd
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250903081823

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:12CENSUS: 8DATE:
10/01/2025
UNANNOUNCEDTIME BEGAN:
09:54 AM
MET WITH:Irene FormenteraTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff did not properly document resident's medications.
Staff did not ensure resident was provided prescribed medications.
INVESTIGATION FINDINGS:
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On 10/01/2025, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent visit to gather information regarding the above allegation. LPA met with Staff and Area Manager Irene Formentera and the purpose of the visit was explained.

Investigation consisted of the following: On 09/04/2025, LPA obtained Personnel Report (dated 07/01/25), Staff Schedule (07/27/25 – 08/02/25), eight Staff Training Records, Register of Residents (08/29/25), R1’s Providence 602, Medication List, X-Ray (07/03/25), Identification and Emergency Information (07/07/25), Preplacement Appraisal Information (07/07/27), Admission Agreement (pages 4 and 47 of 47), July 2025 – August 2025 Medication Administration Record, Providence Plan of Care Medication Profile (08/04/25 – 08/05/25) and Multidisciplinary Field Notes (08/04/25 - 08/05/25), Visitor Sign-In Sheet (07/31/25 – 08/08/25), and Visitor Sign-In Sheet (07/31/25 – 08/08/25), Medication Destruction Record (08/05/25). LPA interviewed Staff #1 – 4. On 09/11/25, LPA interviewed Staff #5 – 7. On 09/17/25, LPA interviewed Staff #8 and Witness #3 - #4, and #7. Continue to LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 11-AS-20250903081823
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: 10/01/2025
NARRATIVE
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 On 10/01/25, LPA retrieved a copy of R1’s Morphine Record (08/04/25), Physician’s Reports (R2 – R6), Updated Training Record (S1) and interviewed Witnesses #1 - #2. Note: LPA left a message/voicemail to interview Witness #5 - # 6, #8 (09/17/25, 09/29/25), and Witness #9 - #10 (09/29/25).

Investigation revealed the following:
Regarding the allegation, “Staff did not properly document resident's medications,” it is being alleged that staff could not locate the medication administration record to confirm if medication was administered to Resident #1 on 08/04/25. Record review of Morphine Record revealed medication was administered to R1 on 08/04/25 10:30 PM by S7. Interview with the Area Manager indicated that the record was placed in the back of the R1’s binder. A second medication record revealed medication was administered on 08/05/25 at 10:30 AM and at 11:13 AM.

Regarding the allegation, “Staff did not properly document resident's medications,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.

Allegation: Staff did not ensure resident was provided prescribed medications.
Regarding the allegation, “Staff did not ensure resident was provided prescribed medications,” it is being alleged that staff did not provide medication A and B according to the doctor’s order. Record review of Hospice medication profile revealed medication A and B is to be given every hour as needed (08/04/25). Record review of Morphine Record revealed medication was administered to R1 on 08/04/25 10:30 PM by S7. Hospice medication profile revealed medication A and B is to be given every two hours, routinely (08/05/25). Hospice notes indicated that R1 received medication A on 08/05/25 at 10:30 AM and at 11:13 AM. Medication B was given on 08/05/25 at 11:13 AM. Interview with Hospice Agency (Witness #1) indicated that the medication was changed from as needed to routine on 08/05/25 around 10:30 AM. Record review of hospice documents revealed that R1 passed away on 08/05/25 12:13 PM.

Regarding the allegation, “Staff did not ensure resident was provided prescribed medications,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Continue to LIC9099-C.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 11-AS-20250903081823
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: 10/01/2025
NARRATIVE
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Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.

An exit interview was conducted and a copy of this report was provided to the Area Manager Irene Formentera.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 11-AS-20250903081823
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: 10/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2025
Section Cited
HSC
1569.69(a)(2)
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(2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing ... and 4 hours of other training or instruction,... first two weeks of employment.
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The Licensee will provide initial medication training hours to staff who assist with medication and email evidence to regina.cloyd@dss.ca.gov. If needed, the Licensee will also ensure that those who assist with medication will also complete the required renewal hours.
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This requirement was not met as evidence by:

Based on record review of straff training and MAR, Staff #1 have not completed six hours of medication training prior to administering medication to Resident #1 which posed a potential health risk to resident in care.
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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: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 8