Cerise Guest Home

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Type of visit: Case Management - Other

On 09/26/2025 at approximately 1:00PM, Licensing Program Analyst (LPA) Jose Anguiano conducted a case management visit and met with Administrator Jehn Demafelix. The facility is a one-story, six-bed, three-bath Residential Care Facility for the Elderly (RCFE), currently housing six residents. LPA toured the facility and observed resident rooms A through F, all of which are licensed for bedridden residents. Of the six residents, two are receiving hospice services. Five residents are non-ambulatory, and one is ambulatory. Two residents utilize hospital beds with full rails. During the visit, LPA collected and reviewed the facility’s hospice service documentation, resident register/roster, LIC 500 Personnel Report, and appraisals for two residents. 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

Type of visit: Case Management - Annual Continuation

On 08/21/25, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Administrator JM Demafelix. The Area Manager Irene Formentera arrived later. On 08/29/25, LPA conducted an unannounced annual continuation. The facility is licensed to serve six (6) residents aged 60 and over. Six (6) bedridden residents are approved in Rooms A, B, C, D, E, and F. There is currently one bedridden resident. The facility has an approved hospice waiver for six (6). Annual Fees are current. The facility is a single-story house located in a residential neighborhood and consists of six (6) bedrooms, three (3) bathrooms, kitchen, activity room, living room, dining room, and an attached garage. The facility is clean, sanitary, and in good repair. The House Manager 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. Common areas were clean, clear of hazards, and doorways were free of obstruction. Continue to LIC809-C. 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, a non-skid mat was in place, and hot water temperature properly measured at 109.6F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept locked. First Aid kit was available. One fire extinguisher, last serviced August 22, 2025 was observed in the kitchen area and in the garage. The Administrator tested the carbon monoxide detector and smoke detectors in the house. Both devices were functional. Six staff records were reviewed and six out of six staff records had the required criminal record clearances or criminal record exemptions. Three resident records were reviewed and three out of three resident records had medical assessments and pre-appraisal or reappraisals. Two residents’ medication was reviewed. No deficiencies are being cited. An exit interview was conducted, technical assistance provided, and a copy of this report was discussed and left with Irene Formentera.the state’s words, verbatim · CDSS document, Aug 29, 2025

Allegation investigated: Unlawful eviction. Staff abandoned resident.

On 08/13/2025, Licensing Program Analyst (LPA) Regina Cloyd conducted an initial visit on to gather information regarding the above allegation. LPA met with House Manager Benito “Jun” Laserna and the purpose of the visit was explained. LPA spoke with Administrator JM Demafelix over the phone. On 08/21/25, LPA met with Administrator and Staff. Investigation consisted of the following: On 08/13/2025, LPA obtained a Register of Residents (dated 05/02/25), and Resident #1’s Physician’s Report (09/09/24), and Needs and Services plan (dated 04/07/25). LPA interviewed Staff #1 – 2. LPA received Torrance Memorial Hospital Medical Records for R1. On 08/14/25, LPA received R1’s Incident Report (04/18/25 and 07/21/25), Appraisal (04/07/25), Physician’s Report (09/09/24), Admission Agreement, SOC 341 (updated 05/05/25), and Eviction Notice (04/14/25). On 08/15/25, LPA received Torrance Memorial Hospital Clinical Notes. On 08/19/25, LPA received R1’s Pre-Appraisal (09/06/24). On 08/21/25, LPA interviewed Staff #1 – 3. Continue to LIC9099-C. Substantiated Investigation revealed the following: Allegation: Unlawful eviction. Record review of the eviction noticed (04/14/25) indicated that R1’s final residency would be 05/14/25. The notice did not include the following requirements: resources available to assist in identifying alternative housing and care options, a statement informing residents of their right to file a complaint with the licensing agency including the name, address and telephone number of the licensing office with whom the licensee normally conducts business, and the State Long Term Care Ombudsman office, and the following exact statement as specified in Health and Safety Code Section 1569.683(a)(4): "In order to evict a resident who remains in the facility after the effective date of the eviction, the residential care facility for the elderly must file an unlawful detainer action in superior court and receive a written judgment signed by a judge. If the facility pursues the unlawful detainer action, you must be served with a summons and complaint. You have the right to contest the eviction in writing and through a hearing." Regarding the allegation, “Unlawful eviction,” based on record review, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. Allegation: Staff abandoned resident. Regarding the allegation, “Staff abandoned resident,” it is being alleged that Resident #1 (R1) was ready for discharge, but the Administrator (S1) refused to accept R1. Record review of Incident Report (07/21/25) revealed R1 complained about mid-section pain. Staff #2 (S2) recommended calling 911 but Witness #1 (W1) stated W1 would take R1. W1 texted S2 on 07/22/25 explaining that R1 would be in the hospital for 10 days to 2 weeks due to UTI. Review of text messages initiated by S1 with W1 revealed that S1 inquired about R1’s location so that S1 could speak with case management about appropriate placement (07/22/25), S1 requested to speak with case manager prior to R1’s return to determine higher level of care (07/28/25), and S1 acknowledged S1 was able to speak with someone from the hospital (07/29/25). Record review of Social Worker notes revealed that the hospital called S1 on 07/29/25, 07/31/25, and 08/06/25 and S1 refused to accept R1 due to R1’s need for a higher level of care. Continue to LIC9099-C. Discharge summary (07/28/25) revealed R1’s diagnosed conditions that were consistent with R1’s Pre-placement Appraisal (09/06/24), Physician's Report (09/09/24) and Reappraisal (04/07/25). The facility’s Plan of Operation for Dementia Care revealed the facility has special techniques for managing behavioral expressions such as avoiding aggressive behaviors, sundowning, and threatening (verbal and nonverbal). Interview with S1 indicated that R1’s behaviors got worse and R1 was throwing things at the dining table, hitting, and scratching. S1 indicated special techniques would have probably worked with W1 and skilled professional support. Regarding the allegation, “Staff abandoned resident,” based on record reviews and interviews, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 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 Area Manager Irene Formentera.the state’s words, verbatim · CDSS document, Aug 21, 2025 · control 11-AS-20250806161340

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(d)(1) · Plan of correction due date: Sep 8, 2025

The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. (1) The notice to quit shall include the following information: This requirement was not met as evidence by: Based on record view of the 30-day notice, the Licensee did not include all of the requirements outline in 87224(d)(1)(B) - 87224(d)(1)(D) which posed a potential personal rights risk to resident in care.the state’s words, verbatim · CDSS document, Aug 21, 2025

Plan of correction: The Licensee will submit a plan of correction to regina.cloyd@dss.ca.gov by the POC due date. The Licesee will also follow the reporting requirements by notifying Licensing of future evictions.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 8, 2025

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations... This requirement was not met as evidence by: Based on record review and interviews, the Licensee did not permit R1 to return back to the facility which posed a potential personal rights risk to the resident in care.the state’s words, verbatim · CDSS document, Aug 21, 2025

Plan of correction: The Licensee will provide proof of correction to regina.cloyd@dss.ca.gov by the POC due date.

Type of visit: Required - 1 Year

On 08/21/25, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Administrator JM Demafelix. The Area Manager Irene Formentera arrived later. The facility is licensed to serve six (6) residents aged 60 and over. Six (6) bedridden residents are approved in Rooms A, B, C, D, E, and F. The facility has an approved hospice waiver for six (6). Annual Fees are current. LPA Cloyd toured the facility and reviewed three resident records. Due to insufficient time, an annual continuation is required. An exit interview was conducted and a copy of this report was provided to the Area Manager Irene Formentera.the state’s words, verbatim · CDSS document, Aug 21, 2025

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

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 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. 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.the state’s words, verbatim · CDSS document, May 7, 2025 · control 11-AS-20250428140245

Type of visit: Prelicensing

On 08/08/2024 at 9:20am, Licensing Program Analyst (LPA) Zina Brown and Licensing Program Manager Janae Hammond conducted an announced visit to the facility for purpose of a pre-licensing evaluation. LPA Zina Brown met with applicant Jehn Maric Demafeliz. An application was submitted to CCLD on 04/25/2024, for an Residential Care Faciity for the Elderly (RCFE) to serve elderly residents and dementia adults for ages 60 and over. The requested capacity is for six (6) bedridden residents. Structure: The facility is a (6) bedroom, (3) bathroom, single story house with a attached garage. The facility is a structure with 6 bedrooms, 3 bathrooms, 1 living room with a TV, and activity room with a TV and board games, a kitchen,and a backyard accessible to residence. There is backyard with a generator, two (2) outside shaded patio areas with a water fall outside on the premises. The resident three (3) bedrooms are spacious and will easily accommodate the residence furnishings. Bedroom Structure All six (6) bedrooms have the following one (1) bed, one (1) lamp, one (1) television, one(1) dresser, one (1) one (1) chair and signal auditory alarm one (1) each sliding door expect for Room F. Room B and Room C residents have a shared bathroom. Bathroom Structure All three (3) bathrooms have a working toilet, wash basin, shower with a rail and a slip grip map and shower chair. All (3) bathrooms can accommodate non-ambulatory clients in a wheel chair. Water temperature for each bathroom are as followed bathroom #1 113.2 F, bathroom #2 116.4 F and bathroom # 3 119.3 F Linens & Hygiene Supplies: Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in the garage. Emergency Phone Numbers, Exit Plan & Menu: The facility has a working phone line and internet. Upon entering the facility to the left of the walkway, is a posted board that & readily available with a evacuation plan, fire prevention, emergency plan, infection control plan and personal right. Fire Extinguisher is located in kitchen door mounted on wall which is fully charged. Food Service: Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are stored in a locked drawer near the refrigerator. Food supply adequate stored in cabinet and consists can goods. The water temperature in the kitchen is at 117.1 F. Dishwasher in kitchen properly installed and functioning. Smoke Detectors: In the facility there are nine (9) smoke detectors with carbon monoxide detectors that are electrical & connected. Battery operated & working. Appliances: In the facility is a working stove burners, oven, microwave, washer, and dryer. There is one (1) refrigerator in the kitchen that is measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit. In the garage is washer and dryer which stores linen for the bedding. The residence is equipped with central air and heat and each client bedroom is individually climate controlled. Toxins: All toxins are locked and stored in. Water Temperature: The water in each bathroom tested at 113.2 degrees Fahrenheit (bathroom 1), 116.4 degrees Fahrenheit (bathroom #2) and 119.3 degrees Fahrenheit (bathroom #3). Medications, First-Aid Kit & Book: A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in kitchen area, available for staff use but inaccessible to residence. Clients & Staff Files: At the time of pre-licensing, no client and staff files were reviewed as the facility is awaiting approval for licensing. Reading Material, Games, Equipment & Materials: The facility has activity with board games, books, and other recreational materials for the client's use. commensurate with the plan of operation. Pool/Jacuzzi & Pets: No located at the time of inspection. Fire clearance: Fire clearance for six (6) bedridden at the residential care facility for the elderly was approved on 05/20/2024. In five (5) bedrooms each have a sliding door with a auditory alarm. Pre-licensing Checklist: Completed by licensee and reviewed by LPA. Component III: During the conducted pre-licensing visit, an orientation of the component III information was provided to the licensee and employees about how to operate the facility within substantial compliance. An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA Zina Brown will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.the state’s words, verbatim · CDSS document, Aug 8, 2024

Type of visit: Office

Facility Type: RCFE Application Type: Initial Capacity: 6 Census (if any clients in care): 0 COMP II Participants: DEMAFELIX, JEHN MARIC - Applicant/Administrator Interview Method: Telephone interview On 07/30/2024, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Jul 30, 2024