Cabrillo Guest Home

Type of visit: Required - 1 Year

On 04/03/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Annual Visit to the facility listed above. LPA met with Administrator, Irene Formentera, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The facility is licensed to serve 6 non-ambulatory residents aged 60 and over, with an approved hospice waiver for four (4). Physical Plant/Structure The facility is a two-story structure located in a residential neighborhood. The first floor consists of four (4) resident bedrooms, two (2) bathrooms, living room, dining room, kitchen, two (2) car garage, and outside has a shaded area. The second floor consists of five (5) bedrooms, three (3) bathrooms, and a den. On the shaded back patio, LPA observed a table and chairs available for resident use. All walkways outside the facility were observed clean, clear, and free of debris, hazards, and obstructions. LPA did not observe any bodies of water on the premises. Bedrooms LPA inspected all residents’ rooms and observed them clean and in good repair. LPA observed resident rooms have the required furniture including a bed(s), dresser(s), nightstand(s), chair(s), and storage space for resident’s personal belongings. LPA observed the beds have the required linens including a mattress cover, fitted sheet, flat sheet, blanket, comforter, and pillows. LPA observed an ample supply of linens. All bedrooms were observed with ample lighting. Bathrooms LPA inspected the bathrooms and found them to be within Title 22 Regulations. All bathrooms were observed clean and operational. All showers have a non-skid mats, shower chair, and secure safety handrails. LPA observed an ample supply of towels and hygiene products available for residents. The water temperature measured 111.3-degrees and 117.6-degrees Fahrenheit. LPA observed an ample supply of incontinent care supplies stored in resident rooms and an additional supply stored in the garage. Kitchen LPA inspected the kitchen and observed it clean and sanitary. LPA observed an ample supply of dishware, cookware, and cutlery. LPA observed that all appliances are operable . LPA observed a 2-day supply of perishable foods, and a 7-day supply of non-perishable foods, properly stored and labeled. LPA observed sharps secured in a locked drawer in the kitchen and are inaccessible to residents. LPA observed cleaning supplies secured in a locked cabinet under the kitchen sink and are inaccessible to residents. The water temperature measured 112.9-degrees Fahrenheit. Common Areas During the time of visit, LPA observed the facility appropriately furnished. LPA observed the living room has five (5) recliners and a couch to accommodate all residents. LPA observed the dining room has a large table with chairs to accommodate all residents. LPA observed games, reading material, and activities available for resident use. LPA observed all walkways and hallways in the facility are clean, clear and free of hazards and obstructions. All hallways and common rooms were observed with ample lighting. The facility was maintained at a comfortable temperature. LPA observed a fireplace that is screened and inaccessible to residents. Medications LPA observed Centrally Stored Medications secured in a locked cabinet in the dining room and are inaccessible to residents and visitor. LPA observed medications in their original packaging. LPA reviewed the medication and Medication Administration Record (MAR) for five (5) residents. LPA observed five (5) out of five (5) resident’s medications are consistent with properly documented records. Files LPA observed resident and staff files secured in a cabinet in the dining room and are inaccessible to residents and visitors. LPA reviewed the files for five (5) residents. LPA observed five (5) residents’ files contain the required documents. LPA reviewed the files for the Administrator and three (3) staff. LPA observed four (4) staff files contain the required clearance, documents, and training. The administrator’s Administrator Certificate, number 7030102740, is valid till 01/11/2027. LPA observed all Licensing Fees are current. Safety LPA observed the last Fire Prevention Inspection conducted by the Torrance Fire Department was on 01/05/2026. The last Emergency Drill was conducted on 02/31/2026. LPA observed a fully charged fire extinguisher that was last serviced on 08/22/2025. LPA observed smoke and carbon monoxide detectors are operable. LPA observed all exits are indicated with an EXIT sign. LPA received and reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E) was lasted reviewed on 09/03/2025. LPA inspected the First Aid Kit and observed it has the required items and a current manual. LPA received and reviewed the liability insurance through Acord, policy number 0012885504, that is valid till 03/22/2027. LPA observed all required postings posted in the facility. The facility has a working landline telephone. There are no firearms or ammunition stored on the premises. Infection Control In the entry of the facility, LPA observed a sanitizing station. LPA observed it consist of a Visitor Sign-In Log and hand sanitizer. LPA observed the required infection control signs posted in the hallway in the facility. LPA observed a 30-supply of Personal Protective Equipment (PPE) stored in the garage. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time. An exit interview was conducted with Administrator, Irene Formentera, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 3, 2026

Type of visit: Case Management - Other

On 09/26/2025 at approximately 9:00 AM, Licensing Program Analyst (LPA) Jose Anguiano conducted a case management visit and with Administrator Jehn Demafelix. The facility is a two-story Residential Care Facility for the Elderly (RCFE) currently housing five residents. LPA toured the facility, observed resident rooms 1 through 4, and conducted a general assessment of the care being provided. Of the five residents, two are receiving hospice services and one is under home health care. All residents are non-ambulatory and utilize hospital beds—two with full rails and two with half rails. The staff consists of two caregivers, one of whom serves as the caregiver manager. During the visit, the facility’s personnel report, resident roster, and service-related documentation were collected and reviewed, and documented on LIC 858. No deficiencies were observed. An exit interview was conducted, and a copy of this report was provided to the Administrator.the state’s words, verbatim · CDSS document, Sep 26, 2025

Allegation investigated: Staff are not able to meet the resident's needs. Staff are not following doctor's orders when administering medication.

On 05/15/2025 Licensing Program Analyst (LPA) Regina Cloyd conducted an initial visit on to gather information regarding the above allegation(s). LPA met with Area Manager Irene Formentera and the purpose of the visit was explained. Investigation consisted of the following : On 05/15/2025, LPA reviewed Personnel Report, Register of Residents, Resident Records (Residents #1 – 5), Resident’s (1 – 5) May Medication Administration Record (MAR), Resident’s (1 – 4) Medication Profiles, observed medication for Residents #1 – 5, and interviewed Residents 1 - 4, Area Manager, and two Caregivers. Investigation revealed the following: LIC9099-C. Unsubstantiated Investigation revealed the following: Allegation: Staff are not able to meet the resident's needs. Record review revealed four out of five residents have a complete Plan of Care/Needs and Services Plan. Four out of four resident interviews indicated that staff can meet their needs. LPA observed that all four residents was alert. Staff interviews indicated that they are able to meet the needs of the residents. Interview with S1 indicated that care services are based on the physician’s report and discussions with the residents and their families. S1 also indicated that care services are adjusted based on staff observations of the residents and discussions with the residents and/or their families. 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 are not following doctor's orders when administering medication Record review of May’s Medication Administration Records and Physician’s Medication Profile are consistent and medication is administered according to doctor’s orders for four out of four residents. Four out of four resident interviews indicated that staff has not made any medication errors. Three out of three staff interviews indicated medication is administered according to doctor’s orders. 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 were issued. An exit interview was conducted, technical assistance provided, and a copy of this report was provided to the Area Manager Irene Formentera.the state’s words, verbatim · CDSS document, May 15, 2025 · control 11-AS-20250507084214

Type of visit: Required - 1 Year

On 03/06/2025 at 08:19am, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced one- year inspection. LPA met with COO JM Demafelix and Irene Formentera, Administrator and the purpose of the visit was discussed. Facility is licensed to serve 6 non- ambulatory residents and an approved hospice waiver for 4 resident from age range 60 and over. Two (2) of the residents are diagnosed with dementia, one (1) resident is receiving home health and one (1) of the residents is hospice & palliative care services. The facility does not handle any of the residents’ money. The facility balance fees are $0. The liability insurance is with James River Insurance Company with each occurrence is $1,000,000 and general aggregate is $3,000,000 which is valid from 03/22/2024 - 03/22/2025. The facility is a 2-story house located in a residential neighborhood and consists of four (4) bedrooms for the residents, two (2) bathrooms and a two (2) car garage, which houses a washer, dryer and an additional refrigerator on the first floor; the second floor consists of five (5) bedrooms, three (3) bathrooms and a den. The home also consists of a living room, dining room, and kitchen on the first floor. The facility is clean, sanitary, and in good repair. Between the hours of 10:25 am - 10:55 am, LPA toured the resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, water temperature measured between 122.1F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions. Report continues of LIC 809-C. Between the hours of 9:20am - 10:15 am, LPA conducted a records review of (5) client records, (5) staff records, (0) clients Personal & Incidental Records and reviewed the facility disaster plan (last fire drill was conducted on 03/02/2025 and earthquake drill was conducted on 02/14/2025. LPA reviewed (4) Client Medication Administration Records and did not observed any discrepancies at the time of visit. All client & Staff records were complete. Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly, and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises. During todays visit LPA did not observe any deficiencies. An exit interview was conducted Irene Formentera (Administrator).the state’s words, verbatim · CDSS document, Mar 6, 2025

Type of visit: Required - 1 Year

On 03/07/24 at 9:07 AM, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with COO JM Demafelix. The Administrator Irene Formentera arrived later. The facility is licensed to serve six (6) elderly residents, all of which (6) may be non-ambulatory with a hospice waiver approved for four (4) aged 60+ years. The facility is a 2-story house located in a residential neighborhood and consists of four (4) bedrooms, two (2) bathrooms and a two (2) car garage on the first floor; the second floor consists of five (5) bedrooms, three (3) bathrooms and a den. The home also consists of a living room, dining room, and kitchen on the first floor. The facility is clean, sanitary, and in good repair. The Administrator accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, hot water temperature properly measured between 119.1F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards, doorways were free of obstructions. Continue to LIC 809-C LPA toured the kitchen and garage area and observed a two day supply of perishable and a seven day supply of non-perishable food. Knives and toxins were kept in locked storage cabinet. First Aid kit was available. One fire extinguisher, last serviced September 26, 2023 was observed in the kitchen area. Administrator tested the carbon monoxide detector and smoke detectors in the house. Both devices were functional. 5 staff records were reviewed, 5 out of 5 staff records had current first aid certificates and required criminal record clearances or criminal record exemptions. Two staff interviews were conducted. 5 resident records were reviewed and, 5 out of 5 resident records had medical assessments and pre-appraisal or reappraisals. Two residents’ medication was reviewed. Two residents were interviewed. No deficiencies are being cited. An exit interview was conducted and a copy of this report was discussed and left with Administrator Irene Formentera.the state’s words, verbatim · CDSS document, Mar 7, 2024