198204399-6-2-2026-11-AS-PMAA-DWEUUY-20260728155417

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204399
Report Date: 06/02/2026
Date Signed: 06/02/2026 03:04:17 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
05/27/2026 and conducted by Evaluator Zina Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20260527154622

FACILITY NAME:	VILLA REDONDO CARE HOME		FACILITY NUMBER:	198204399
ADMINISTRATOR:	MARIA BRAVO		FACILITY TYPE:	740
ADDRESS:	237 REDONDO AVENUE		TELEPHONE:	(562) 434-9931
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90803
CAPACITY:	80; 80	CENSUS: 56	DATE:	06/02/2026
		UNANNOUNCED	TIME BEGAN:	08:20 AM
MET WITH:	Jesse Chavez (Assistant Administrator)		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Staff did not ensure the resident attended their religious services on time.

INVESTIGATION FINDINGS:

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On 06/02/2026 at 8:20am, the Department arrived at the facility to conduct an initial visit to investigate the allegation listed above. During today’s visit, the Department met with Jesse Chavez (Assistant Administrator) and explained the purpose of the visit.

The investigation consisted of the following: On 06/02/2026, the Department conducted interviews between the hours of 9:35am - 11:28am with the Administrator (A1), Staff (S1-S5) and Residents (R1-R6). The Department also requested and obtained copies of the staff roster (dated 05/15/2026), resident roster (received on 06/02/2026) and R1's documents such as Admission Agreement (dated 08/08/2025), LIC 602 Medical Assessment for RCFE (dated 08/25/2025), LIC 603 Preplacement Appraisal Information (not dated), LIC 613C-2 Personal Rights In Privately Operated Residential Care Facilities for the Elderly (dated 08/25/2025), Personal Rights Policy (GP02) (dated 06/01/2025), Resident Sign-In / Sign-Out Policy (GP08) (dated 12/13/2024) and Resident Sign In/Out Log (March 2026-May 2026).

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

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-20260527154622

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: VILLA REDONDO CARE HOME	FACILITY NUMBER: 198204399
	VISIT DATE: 06/02/2026

NARRATIVE

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Medical appointments were documented on Monday 03/23/2026, Saturday 03/28/2026, Wednesday 04/22/2026, Wednesday 04/29/2026, Thursday 04/30/2026, Friday 05/01/2026, and Saturday 05/16/2026. Additional outings were recorded on Saturday 03/28/2026, Tuesday 03/31/2026, Monday 04/13/2026, Sunday 04/19/2026 (including a 9:08 coffee outing), Friday 04/24/2026, and Tuesday 05/26/2026. The log demonstrates that R1 regularly departs the facility without documented restriction, and staff consistently facilitate R1's ability to leave for community activities, including religious services, in accordance with facility policy and resident personal rights.

Based on information gathered through interviews and record reviews, there is not enough evidence to support the allegation. 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. Therefore, the allegation is UNSUBSTANTIATED.

Exit interview conducted with Jesse Chavez (Assistant Administrator) and a copy of this report was provided.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20260527154622

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: VILLA REDONDO CARE HOME	FACILITY NUMBER: 198204399
	VISIT DATE: 06/02/2026

NARRATIVE

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The investigation revealed the following:

Allegation: Staff did not ensure the resident attended their religious services on time.
It was alleged that on the morning of the incident, a staff member refused to allow R1’s family member to sign R1 out at the agreed upon time of 9:00am, as previously approved by facility management. The family member reported being unable to sign R1 out until 9:30am, resulting in a late arrival to church, and stated they were on the phone with R1 during the delay.

On 06/02/2026 between 9:35am - 9:55am, the Department interviewed A1. A1 denied the allegation and stated that R1’s family member may sign R1 out at any time based on R1’s personal rights. A1 stated that staff may ask visitors to wait if the lobby floor is being mopped between 9:00am - 9:30am to prevent fall risk. A1 reported that no incident report was completed and stated the facility has filed multiple SOC 341 forms regarding the family member’s behavior towards R1.

On 06/02/2026, between 9:01am -11:28am, the Department interviewed 5 staff in regards the allegation. 4 out of 5 staff denied the allegation, stating that no staff refused or delayed the sign-out and explained that the lobby is typically closed until 9:30am due to housekeeping mopping the floors, requiring residents to be escorted downstairs during that time to prevent fall risk. Staff reported that R1’s family member arrived early at approximately 8:35am before staff were present in the lobby, and 1 staff stated that similar situations have occurred once or twice before on Sundays. Staff consistently stated that residents may leave whenever they choose and that the facility does not restrict religious attendance. 1 out of 5 staff was unaware of the allegation, stating they were not on duty and could not confirm what occurred.

On 06/02/2026 between the hours of 9:28am - 10:53am, the Department interviewed 6 residents regarding the allegation. 6 out of 6 residents denied the allegation, stating they had not experienced staff refusing or delaying sign outs and had not witnessed staff preventing a resident’s family member from signing them out at an agreed upon time. Residents reported that staff allow them to leave when requested, that staff respect their rights, and that any waiting is due to staff assisting other residents or normal delays. R1 stated that they usually leave on time and that any delays are rare and related to staff assisting multiple residents, not refusal. No residents reported being aware of or observing the alleged incident.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20260527154622

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: VILLA REDONDO CARE HOME	FACILITY NUMBER: 198204399
	VISIT DATE: 06/02/2026

NARRATIVE

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On 06/02/2026 between 1:00pm -2:15pm, the Department conducted a records review and observed the following: According to R1's Admission Agreement (dated on 08/28/2026) on page 8 under section 12. Facility Visiting Policy states: The facility encourages visiting between the resident and family/or friends. (a) facility visiting hours are: Monday through Sunday 9am - 7pm. On page 17, 13. Visiting hours are from 9am to 7pm daily. Visitors are required to use the visitors log to sign in and out. Arrangements can be made for special visits at any time. On page 28 in the Policies Concerning Family Visits the facility encourages visits from family, friends and clergy. Please feel free to visit from 9am - 7pm. If additional visiting times are needed, please contact the facility in advance to make arrangements. Also according to R1's LIC 613C-2 Personal Rights In Privately Operated Residential Care Facilities for the Elderly (signed & dated 08/25/2025 by R1) on page 5 of 8 it states (24) To consent to have relatives and other individuals of the resident's choosing visit during reasonable hours, privately and without prior notice.

The facility’s Personal Rights Policy (GP02) (dated 06/01/2025) which states that residents have the right to attend religious services of their choice inside or outside the facility and the right to leave the facility at any time. The policy does not authorize staff to delay or restrict a resident’s ability to depart for religious services. The Resident Sign-In/Sign-Out Policy (GP08) (dated 12/13/2024) requires residents to sign out when leaving but does not impose time restrictions, require prior approval, or permit staff to delay a resident’s departure. The policy does not reference any limitation related to religious outings or scheduled pick up times. Based on the policies reviewed, residents are permitted to leave freely with their authorized representative, and staff are required to support residents’ rights to attend religious services without interference or delay.

The Department reviewed the Resident Sign-In/Out Log for March 2026 - May 2026. The log reflects that R1 routinely leaves the facility with her authorized representative for various outings, including frequent trips to the beach, shopping, meals, medical appointments, and other community activities. R1 signed out to the beach on multiple dates including Monday 03/02/2026, Saturday 03/07/2026, Monday 03/09/2026, Thursday 03/12/2026, Friday 03/13/2026, Monday 03/16/2026, Tuesday 03/17/2026 at 9:50 AM, Sunday 05/03/2026, Monday 05/04/2026, Thursday 05/07/2026, Saturday 05/16/2026, Friday 05/22/2026, Sunday 05/24/2026, Saturday 05/30/2026, and Sunday 05/31/2026. R1 also signed out for shopping or meals on Thursday 03/12/2026, Friday 03/13/2026, Wednesday 04/24/2026, Sunday 04/26/2026, Tuesday 04/28/2026, and Tuesday 05/12/2026.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2026

LIC9099 (FAS) - (06/04)

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