198320492-5-7-2025-11-AS-UCOL-DH9SJM-20250602135523

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320492
Report Date: 05/07/2025
Date Signed: 05/07/2025 04:08:06 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
04/28/2025 and conducted by Evaluator Regina Cloyd

COMPLAINT CONTROL NUMBER: 11-AS-20250428140245

FACILITY NAME:	CERISE GUEST HOME		FACILITY NUMBER:	198320492
ADMINISTRATOR:	DEMAFELIX, JEHN MARIC		FACILITY TYPE:	740
ADDRESS:	22525 CERISE AVENUE		TELEPHONE:	(310) 533-1131
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY:	6	CENSUS: 3	DATE:	05/07/2025
		UNANNOUNCED	TIME BEGAN:	09:33 AM
MET WITH:	House Manager Benito Laserna		TIME COMPLETED:	04:25 PM

ALLEGATION(S):

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Resident sustained unexplained injuries while in care.
Staff mismanaged resident's medications.
Staff did not report incident to resident's authorized representative.

INVESTIGATION FINDINGS:

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On 05/07/25, LPA Regina Cloyd conducted a subsequent visit and met with House Manager. On 05/02/25, Licensing Program Analyst (LPA) Regina Cloyd conducted an initial visit to gather information regarding the above allegations. LPA met with House Manager Benito Laserna and the purpose of the visit was explained.

Investigation consisted of the following: On 05/07/25, LPA interviewed Resident #2 and attempted to interview Resident #3. Resident #4 was unavailable. LPA also interviewed Witness #2 and left voicemails for Witnesses #1 and #3. Resident #1 no longer lives at the facility. On 05/02/25, LPA reviewed facility documents, Resident #1 (R1) record, R1’s medication record, and interviewed the House Manager and two Caregivers.

Investigation revealed the following:
Continue to LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

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 3

Control Number 11-AS-20250428140245

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: CERISE GUEST HOME	FACILITY NUMBER: 198320492
	VISIT DATE: 05/07/2025

NARRATIVE

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Regarding the allegation "Resident sustained unexplained injuries while in care,” it is being alleged that Resident #1 (R1) sustained a black eye in January 2025 and a scrape/cut on knee in March 2025.

Record review of R1’s Mobile Physicians Report (01/23/25) revealed that R1 did not have swelling or tenderness of the face over the periorbital area of the right eye during the standard exam. The report also described problem #2 as a contusion of the periorbital area on the right. Four out of four Staff (#1 – 4) interviews indicated R1 did not have a black eye. Interview with Staff #1 (S1) and Staff #3 indicated that it is possible that R1’s face hit the table while R1 was asleep in R1’s chair while wearing glasses. S1 indicated that staff tries to encourage R1 to sleep in the bed but R1 would eventually go back to the chair. Interview with S1 and Staff #2 (S2) indicated that R1 had a little bump on R1’s knee and R1 scratched it. They added a bandage but R1 removed it. Interview with Resident #2 (R2) indicated R2 has not sustained any unknown injuries while in care and is unaware if other residents had sustained unknown injuries. Interview with Witness #2 indicated Resident #3 has not sustained any unknown injuries while in care and is unaware if other residents had sustained unknown injuries.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Staff mismanaged resident's medications

Regarding the allegation "Staff mismanaged resident's medications,” it is being alleged that Resident #1 (R1) was given the wrong medication and was unrecognizable the last week of February and the beginning of March 2025.

Medication Administration Record (MAR) revealed that R1 took Quetiapine 100mg and Divalproex 250mg twice per day in February 2025. In addition, on 02/06/25, R1 started taking Sertraline HCL (Zoloft) 50mg. On 02/17/25, R1 started taking Sertraline HCL (Zoloft) 100mg daily. Plus, on 02/25/25, R1 started taking Trazodone 50mg twice per day from 02/25/25 – 02/28/25. Record review of Mobile Physician report (03/06/25) revealed Quetiapine 100mg was prescribed twice per day as of 01/16/25. Divalproex 250mg was prescribed twice per day as of 04/25/24. Record review of Mobile Physician report (faxed 02/04/25) revealed Zoloft 50mg was prescribed once per day.
Continue to LIC9099-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 05/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20250428140245

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: CERISE GUEST HOME	FACILITY NUMBER: 198320492
	VISIT DATE: 05/07/2025

NARRATIVE

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Record review of Mobile Physician report (03/06/25) revealed Zoloft 100mg was prescribed once per day as of 02/17/24. Trazodone 50mg was prescribed once per day as of 02/24/25. Record review of Staff #1’s (S1) 02/28/25 memo to the Administrator revealed that R1 was no longer the same since taking Trazodone. The memo included descriptions of R1’s change of condition from being active to being drowsy, wobbly, and unsteady. R1’s March 2025 MAR revealed that Trazodone and Divalproex 250mg was discontinued on 02/28/25. MAR revealed R1 took Quetiapine 100mg twice per day from 03/01/25 to 03/06/25 and Zoloft 50mg + 100mg daily at bedtime from 03/01/25 to 03/05/25. LPA observed that the common side effects for Trazodone includes drowsiness, dizziness, and fatigue (source: google). Three out of three staff (#1 – 3) interviews denied the allegation and indicated that R1 had a changed of behavior after being prescribed Trazodone. Two out of two staff interviews indicated that the effects of the Trazodone was discussed with R1’s daughter. Interview with Resident #2 (R2) indicated staff has not mismanaged R2’s medication. Interview with Witness #2 indicated that staff has not mismanaged Resident #3’s medication.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Staff did not report incident to resident's authorized representative.

Regarding the allegation "Staff did not report incident to resident's authorized representative,” it is being alleged that staff did not report Resident #1’s (R1) injuries to authorized representative. On 01/22/25, Community Care Licensing received an unusual incident report for R1. Record review of R1’s Mobile Physician’s Report (01/23/25) indicated that Staff #1 (S1) did not report the bruise under the eye because it was small and the cause was unknown. Interview with Staff #2 indicated that R1’s knee scratch in March it was explained to R1’s family and to S1. Interview with Resident #2 indicated that the care staff will contact R2’s family if an incident occurred. Interview with Witness #3 indicated that staff will report incidents to Resident #3’s authorized representative.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.
No deficiencies issued.
An exit interview was conducted with Area Manager Irene Formentera and House Manager Benito Laserna 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: 05/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

LIC9099 (FAS) - (06/04)

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