197608376-10-15-2025-11-AS-UCOL-DNM37W-20251120170034

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608376
Report Date: 10/15/2025
Date Signed: 10/15/2025 04:26:44 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
09/03/2025 and conducted by Evaluator Regina Cloyd

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20250903081823

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	CENSUS: 8	DATE:	10/15/2025
		UNANNOUNCED	TIME BEGAN:	02:12 PM
MET WITH:	Staff Emmeie Mina		TIME COMPLETED:	04:41 PM

ALLEGATION(S):

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Staff left residents unsupervised for an extended period of time.

INVESTIGATION FINDINGS:

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On 10/15/25, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent visit to gather information regarding the above allegation. LPA spoke with Area Manager Irene Formentera over the phone 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: 10/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025

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-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: 10/15/2025

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. On 10/13/25, LPA received R1’s records from Home Care Visit in Providence Hospice LA County. 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).

Allegation: Staff left residents unsupervised for an extended period of time.

Regarding the allegation, “Staff left residents unsupervised for an extended period of time,” it is being alleged that only a cleaning lady and kitchen staff was present on 08/05/25 9:30 AM – 11:30 AM. Record review of Home Care Visit in Providence Hospice LA County revealed although there was a cook and housekeeper, there was no caregiving staff to give meds. Review of staff schedule (08/05/25) revealed S1 worked from 6:00 AM - 6:00 PM, S6 worked from 7:00 AM - 4:00 PM, and S8 worked from 11:00 AM - 8:00 PM. Personnel Report revealed S1, S6, and S8 as Caregivers. Four out of four staff interviews (S3, S5, S6, S8) indicated that residents were not left unsupervised. Interview with S1 indicated that S1 worked on 08/05/25 during 9:30 AM – 11:30 AM and S1 replaced colleague in the kitchen. S1 indicated that S1 is a Caregiver. S6 indicated that S1 was at the facility and was covering for the Cook and S8 worked during that time frame. S8 indicated that S8 arrived to the facility around 10:40 AM and coworkers S1 and S6 were on site. S8 indicated that S1 and S6 are caregivers and residents are not left unsupervised. Two out of three witness interviews (W3-W4, W7) indicated that the facility provide adequate supervision.

Regarding the allegation, “Staff left residents unsupervised for an extended period of time,” based on record review 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.

An exit interview was conducted over the phone with Area Manager Irene Formente and a copy of this report was left with Staff Emmeie Mina.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 10/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2025

LIC9099 (FAS) - (06/04)

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