Redondo Beach Elderly Home

Allegation investigated: Staff did not administer medication as prescribed.

**This report supersedes the original report delivered on 2/6/2025. On 5/7/2026, Licensing Pogram Analyst (LPA) Bernadette Allen arrived at the facility to deliver the corrected 9099, providing clarification on the original report issued on 2/6/2026. ** On 2/6/2026, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegations. LPA identified herself and met with Support Staff Emilita Mina (Emmie) who was informed of the purpose of the visit. On 2/5/2026, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to investigate and deliver findings for the alleged allegations. LPA identified herself and met with Support Staff Emilita Mina (Emmie) who was informed of the purpose of the visit. Continued Unsubstantiated Investigation consisted of the following: On 2/5/2026 LPA reviewed and obtained Resident Roster dated 12/26/2025 which was updated during the visit with the current residents in care and staff roster dated 1/22/2026, Medication Administration Record (MAR) from 1/1/2026-2/5/2026 and Morphine Record from 7/5/2025 through 2/5/2026, Preplacement appraisal dated 3/14/2024,/RCFE levels of care assessment tool dated 3/14/2024, physicians report dated 3/19/2024, and updated appraisal/needs and services plan dated 1/20/2026 signed on 2/3/2026 electronically. As well as an random review of residents’ medication administration records (MAR) Investigation revealed the following: Allegation 2: Staff did not administer medication as prescribed. LPA conducted interviews with staff members 1-5(S1–S5) and 5 out of 5 stated residents’ medications are not mismanaged and residents are given their medications as prescribed by their physicians daily. LPA attempted to interview Residents 1–9 (R1–R9), who were asleep at the time of the visit. However, LPA was able to successfully interview Residents 10–11 (R10–R11) who stated they receive medication daily. When asked who gave their medication, they were both unable to provide details or names of staff members. LPA conducted a random review of residents’ medication administration records (MAR) and obtained documentation for R1. The records revealed that 5 out of 5 files reviewed reflects that the staff are managing residents’ medication and administering medications as prescribed by their physicians. Based on the interviews, records reviewed and observations the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegation is determined to be Unsubstantiated. An exit interview was conducted where this report was discussed and provided to Irene Formentera at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, May 7, 2026 · control 11-AS-20260130130622

Allegation investigated: Staff did not prevent a resident from eloping from the facility.

**This report supersedes the original report delivered on 2/6/2025. On 5/7/2026, Licensing Program Analyst (LPA) Bernadette Allen arrived at the facility to deliver the corrected 9099 providing clarification on the original report issued on 2/6/2026. ** On 2/6/2026, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegation. LPA identified herself and met with Support Staff Emilita Mina (Emmie) who was informed of the purpose of the visit. Area manager-Irene Formentera arrived about 10AM and she was informed of the purpose of the visit. LPA attempted to interview Residents 1–9 (R1–R9), who were asleep at the time of the visit. However, LPA was able to successfully interview Residents 10–11 (R10–R11). Continued.... Substantiated Investigation revealed the following: Allegation #1: Staff did not prevent a resident from eloping from the facility. On 2/6/2026 At 8:45 AM, LPA conducted interviews with staff members, and 3 out of 5 staff stated that R1 did elope from the facility without staff knowledge. The interview with Staff 1 (S1) confirmed that R1 had eloped from the facility without staff’s knowledge and was located at approximately 8:00 AM on the same day. Interviews with Staff 2–3 (S2–S3) revealed they were not scheduled to work during the incident; however, they reported hearing about R1 eloping from the facility. Staff 4–5 (S4–S5) also stated that R1 did elope from the facility on January 16, 2026, at approximately 7:00 AM and was found at approximately 8:00 AM the same day. LPA attempted to interview Residents 1–9 (R1–R9); however, they were asleep during the visit and could not be interviewed. LPA interviewed Resident 10 (R10), who stated they had left the facility but were unable to provide specific details about the incident. Resident 11 (R11) stated they have not left the facility but expressed a desire to return to their home. Based on interviews conducted, observations and records reviewed the preponderance of evidence standard has been met, therefore the above allegation 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, and a copy of the report was provided to Area Manager- Irene Formentera at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, May 7, 2026 · control 11-AS-20260130130622

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Feb 12, 2026

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Based on interviews conducted on February 5, 2026, and February 6, 2026, at approximately 7:00–8:00 AM, it was determined that R1 eloped from the facility without staff’s knowledge. This incident poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, May 7, 2026

Plan of correction: The licensee and area manager have agreed to provide additional training to all staff on the cited regulation to prevent future resident elopements. Manager has also implimented additional auditory devises to R1's bed and door which has been agreed upon with the family. LPA observed at the time of visit. Proof of completed training and statement of understanding signed by all staff members, will be emailed to the Department upon completion. Bernadette.Allen@dss.ca.gov by the Plan of Correction (POC) due date of February 12, 2026.

Type of visit: Required - 1 Year

On 04/08/2026, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Staff. The Area Manager Irene Formentera arrived later. The facility is licensed to serve twelve (12) non-ambulatory residents age 60 and above. Four residents may be bedridden and rooms 1, 2, & 9 are cleared for bedridden. The facility has a hospice waiver for seven (7) residents. Annual Fees are current. The facility is a single-story family home located in a residential neighborhood. It consists of an attached garage (includes laundry area), front office, nine resident bedrooms (#1 - #9), five bathrooms, dining area, and living room. A shaded area furnished with outdoor patio furniture, including tables and chairs, surrounding the perimeter. Area 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 facility were clear of hazards. Resident bedrooms had bed linens and closet/drawer space to accommodate each resident comfortably. Continue to LIC809-C. There are no security bars or weapons on the premises. The Fire Department conducted a fire prevention inspection on 04/02/2026. A disaster drill was conducted by the facility on 03/10/2026. Resident bathrooms were checked. Toilets worked properly, grab bars were secure, a non-skid mat was in place in the showers. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards. Doorways were free of obstructions. 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 were kept in a locked cabinet in the kitchen. First aid kit was available. Fire extinguishers were serviced August 22, 2025 and are located in the garage and in the hallway. Five (5) staff records were reviewed, five (5) out of five (5) staff records had current first aid certificates and required criminal record clearances or criminal record exemptions. Five (5) resident records were reviewed, five (5) out of (5) resident records had medical assessments and pre-appraisal or reappraisals. Two residents’ medications were reviewed. A deficiency with civil penalty is being cited according to California Code of Regulations, see LIC809-D and LIC421IM. During the facility tour, between 10:30 AM - 10:55 AM, LPA measured the hot water temperature in the common, shared (rooms 4 and 9), and half bathrooms (near room 7) to be between 140 – 150 degree Fahrenheit. LPA did not observe a warning caution sign concerning hot water temperature. Continue to LIC809-C. LPA verified the temperature reading with Irene in room 4. Around 4:15 PM, LPA tested water temperature in room 7 and it measured at 125 degree Fahrenheit and the Resident #3 is ambulatory. An exit interview was conducted, plans of correction developed, technical assistance provided, and a copy of this report with appeal rights was discussed and left with Area Manager Irene Formentera.the state’s words, verbatim · CDSS document, Apr 8, 2026

The state marks this report as 8 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Allegation investigated: Client sustained an injury (bump to the head) due to staff neglect or physical abuse

On 02/19/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Complaint Visit to the facility listed above. LPA met with Administrator, Jehn 'JM' Maric Demafelix, and the purpose of today’s visit was explained. LPA was granted entry into the facility. The investigation consisted of the following: During today’s visit the department inspected the facility, interviewed Staff S1-S5, interviewed Residents R2-R5, interviewed resident’s Responsible Party W1-W3, and received documents pertinent to the investigation. The following documents were received and reviewed Staff Roster, Resident Roster, Staff Relias Transcript, Staff's Statement Acknowledging Requirement to Report Suspected Abuse to Dependent Adults or Elders, R1’s Medical Assessment dated 01/28/2026, Preplacement Appraisal Information dated 01/29/2026, R1’s Personal Rights dated 01/30/2026, and Admission Agreement dated 01/30/2026. The investigation revealed the following: Unsubstantiated Allegation: Client sustained an injury (bump on the head) due to staff neglect or physical abuse The allegation alleges that a resident had a bump and bruise to the right side of the forehead and staff were unable to explain how the resident sustained the injury. During the facility inspection LPA was looking to observe or identify any signs of neglect, abuse, or other immediate health and safety threats. LPA observed staff assisting residents from breakfast to either their room or common area and cleaning. LPA observed staff assisting residents with activities of daily living (ADL’s) such as toileting, changing, bathing, grooming, and transferring. Additionally, LPA observed staff going into residents’ rooms to see if they required assistance and asking how they are doing and feeling. During record review, LPA received and reviewed staff’s Relias Transcript that indicate staff have received training regarding Overseeing, Reporting, and Documenting, Recognizing a Change in Condition, and How to Recognize and Report Skin Condition. LPA received and reviewed R1’s Personal Right of Residents (LIC 613C) dated and signed by R1's Responsible Party on 01/30/2026 that states resident’s have the right “to be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse.” LPA observed Residents Personal Rights posted on a board in the common area. During interviews with Resident’s R2-R5 were asked if they have observed or have any concerns regarding neglect from the staff, four (4) out of four (4) stated they have not observed nor do they have any concerns regarding neglect. During interviews with Staff S1-S5 were asked were asked whether residents are neglected, five (5) out of five (5) stated residents in care are not neglected. Additionally, five (5) out of five (5) stated they have not seen a staff neglect or physically abuse a resident. During interviews with resident’s Responsible Party W1-W3, were asked if they have any concerns regarding neglect, two (2) out of three (3) stated they do not have any concerns regarding neglect. During the course of the investigation, LPA was unable to find evidence to support the allegation(s). Although the allegation(s) may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation(s) is/are unsubstantiated. During today’s visit, LPA did not observe or cite any deficiencies. An exit interview was conducted with Administrator, Jehn 'JM' Maric Demafelix, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Feb 19, 2026 · control 11-AS-20260213150937

Allegation investigated: Staff did not prevent a resident from eloping from the facility.

On 2/6/2026, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegation. LPA identified herself and met with Support Staff Emilita Mina (Emmie) who was informed of the purpose of the visit. Area manager-Irene Formentera arrived about 10AM and she was inform of the purpose of the visit. Investigation consisted of the following: On 2/5/2026 LPA reviewed and obtained Resident Roster dated 12/26/2025 which was updated during the visit with the current residents in care and staff roster dated 1/22/2026, Medication Administration Record (MAR) from 1/1/2026-2/5/2026 and Morphine Record from 7/5/2025 - 2/5/2026, Preplacement appraisal dated 3/14/2024,RCFE levels of care assessment tool dated 3/14/2024, physicians report dated 3/19/2024, and updated appraisal/needs and services plan dated 1/20/2026 signed on 2/3/2026 electronically for resident 1(R1). LPA attempted to interview Staff member 1 (S1) and conducted interviews with staff members 2-5 (S2-S5). Substantiated LPA also interviewed resident 1-2 (R1-R2) and attempted to interview residents 3-9 (R3-R9) during the visit. On 2/6/2026 At 8:45 AM, LPA was able to conduct an interview with S1. Investigation revealed the following: Allegation: Staff did not prevent a resident from eloping from the facility. LPA conducted interviews and 3 out of 5 staff members stated R1 did elope from the facility without staff knowledge. The interview with S1 stated R1 had eloped from the facility without staff’s knowledge and located about 8:00AM the same day. The interviews conducted with Staff 2-3 (S2-S3) stated they were not scheduled to work during the incident but heard about R1 eloping from the facility. Staff members 4-5 (S4-S5) also stated R1 did elope from the facility on January 16, 2026, at approximately 7:00 AM and was found approximately about 8:00AM the same day. LPA interviewed Resident 1 (R1), who stated they left the facility but were unable to provide specific details about the incident. Resident 2 (R2) stated they have not left the facility but expressed a desire to return to their home. LPA attempted to interview Residents 3- 9 (R3–R9); however, they were asleep during the visit and could not be interviewed. Upon arrival, LPA observed that the auditory alert device at the front entry was turned on and approximately about 10:40 AM it was turned off by S4 and later turned back on at approximately about 12:00 PM. Based on interviews conducted, observations and records reviewed the preponderance of evidence standard has been met, therefore the above allegation 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, and a copy of the report was provided to Area Manager- Irene Formentera at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Feb 6, 2026 · control 11-AS-20260130130622

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Feb 12, 2026

Basic services shall at a minimum include: Care and supervision as defined in Section 87101(e)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: Based on interviews conducted on February 5, 2026, and February 6, 2026, at approximately 7:00–8:00 AM, it was determined that R1 eloped from the facility without staff’s knowledge. This incident poses an immediate health, safety, and personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Feb 6, 2026

Plan of correction: The licensee and area manager have agreed to provide additional training to all staff on the cited regulation to prevent future resident elopements. Manager has also implimented additional auditory devises to R1's bed and door which has been agreed upon with the family. LPA observed at the time of visit. Proof of completed training and statement of understanding signed by all staff members, will be emailed to the Department upon completion. Bernadette.Allen@dss.ca.gov by the Plan of Correction (POC) due date of February 12, 2026.

Allegation investigated: Staff did not administer medication as prescribed.

On 2/6/2026, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to deliver findings for the alleged allegations. LPA identified herself and met with Support Staff Emilita Mina (Emmie) who was informed of the purpose of the visit. On 2/5/2026, Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced visit to investigate and deliver findings for the alleged allegations. LPA identified herself and met with Support Staff Emilita Mina (Emmie) who was informed of the purpose of the visit. Investigation consisted of the following: On 2/5/2026 LPA reviewed and obtained Resident Roster dated 12/26/2025 which was updated during the visit with the current residents in care and staff roster dated 1/22/2026, Medication Administration Record (MAR) from 1/1/2026-2/5/2026 and Morphine Record from 7/5/2025 through 2/5/2026, Preplacement appraisal dated 3/14/2024,/RCFE levels of care assessment tool dated 3/14/2024, continued ... Unsubstantiated physicians report dated 3/19/2024, and updated appraisal/needs and services plan dated 1/20/2026 signed on 2/3/2026 electronically. LPA attempted to interview Staff Member 1 (S1), but they were unavailable. LPA conducted interviews with staff members 2-5 (S2-S5). On 2/6/2026 At 8:45 AM, LPA was able to conduct an interview with S1. LPA also interviewed resident 1-2 (R1-R2) and attempted to interview residents 3-9 (R3-R9) during the visit. Investigation revealed the following: Allegation 2: Staff did not administer medication as prescribed. LPA conducted interviews with staff members 1-5(S1–S5) and 5 out of 5 stated residents’ medications are not mismanaged and residents are given their medications as prescribed by their physicians. Additionally, LPA conducted interviews with residents 1 and 2 (R1–R2) and 2 out of 11 stated that they receive medication daily. When asked who gave their medication, they were both unable to provide details or names of staff members. LPA attempted to interview Residents 3 through 9 (R3–R9); however, they were sleep/unavailable during the visit. LPA conducted a random review of residents medication administration records (MAR) and obtained documentation for R1. The records revealed that 5 out of 5 files reviewed reflects that the staff are managing residents’ medication and administering medications as prescribed by their physicians. Based on the interviews, records reviewed and observations the Department found no evidence to support the above allegations. While the allegations may be valid or have occurred, there is insufficient evidence to establish whether the alleged violations took place or did not. Therefore, the allegation is determined to be Unsubstantiated. An exit interview was conducted where this report was discussed and provided to Irene Formentera at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Feb 6, 2026 · control 11-AS-20260130130622

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Bernadette Allen conducted an unannounced case management visit. Irene Formentera was informed that, as part of complaint investigation 11-AS-20260130130622 the following observations were made. LPA observed the following: The auditory alert device at the front entry was turned on; however, at approximately 10:40 AM, staff member S4 turned the device off, and it was later turned back on at approximately 12:00 PM. Per the licensee’s care plan and Title 22, Division 6, Chapter 8 – Care of Persons with Dementia, the auditory alert device must remain active at all times. Failure to maintain this device continuously poses a immediate health and safety risk to persons in care. The Area Manager was informed that the auditory alert device should not be used intermittently. Based on these observations, a citation will be issued for noncompliance with Title 22 regulations on the LIC809-D An exit interview was conducted, and a copy of the report was provided to Area Manager- Irene Formentera at the conclusion of the visit with appeal rights.the state’s words, verbatim · CDSS document, Feb 6, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87705(d) · Plan of correction due date: Feb 7, 2026

(d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors and perimeter fence gates accessible to those residents who may be at risk for elopement, as defined in Section 87101, Definitions. This requirement was not met as evidenced by: Based on LPA observations on February 5, 2026, staff intermittently turned the auditory alert device on and off at the front entry door. Staff were advised that the device must remain activated continuously.the state’s words, verbatim · CDSS document, Feb 6, 2026

Plan of correction: The licensee and area manager have agreed to provide additional training to all staff on the cited regulation to prevent future resident elopements. Proof of completed training with a statement of understanding, signed by all staff members, will be emailed to the Department upon completion. Bernadette.Allen@dss.ca.gov by the Plan of Correction (POC) due date of February 7,2026.

Allegation investigated: Staff did not inform responsible party of resident's change of condition.

On 11/05/25, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent visit to deliver findings regarding the above allegation. LPA met with Staff and 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 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. On 10/16/25, LPA interviewed Witness #11. On 10/17/25, LPA interviewed Witness #5, #7, #9 and #10. On 10/30/25, LPA received R1’s death certificate. On 11/03/25, LPA interviewed Staff #9 - #10. Note: LPA left a message/voicemail to interview Witness #6, #8 (09/17/25, 09/29/25, 10/17/25). Regarding the allegation, “Staff did not inform responsible party of resident's change of condition,” it is being alleged that R1 collapsed on 07/29/25 and the responsible parties were not notified. Record review of Home Care Visit in Providence Hospice LA County (Encounter Notes) revealed on 07/29/25, R1 lost consciousness after dinner, per B&C caregiver. R1 was taken to his bed, however, R1’s health continued to decline and R1 became unresponsive and bedbound since 08/01/25. Record review of staff schedule (07/29/25) revealed that S7 worked from 3 PM - 12 AM, S3 worked from 6 AM - 6 PM, S8 worked from 11 AM - 8 PM, S1 worked from 7 AM - 4 PM, and S6 worked from 12 AM - 9 AM. Interview with Hospice Nurse (Witness 11) indicated W11 was unable to recall the name of the B&C caregiver but indicated that the staff was a woman (S1, S3, S6 - S7). Five out of five staff interviews (S1, S3 and S6-S8) indicated R1 did not collapse nor fall. Interview with the Administrator indicated that there were no reports of R1 collapsing. S7 indicated that R1 did not collapse but during dinner, S7 noticed R1 was getting tired so R1 was assisted to R1’s room. Four out of six responsible party/witness interviews (W4 – W7, W9 - W10) indicated they are notified of incidents and changes of resident’s condition. Regarding the allegation, “Staff did not inform responsible party of resident's change of condition,” based on record reviews 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 Formentera and a copy of this report was provide to Staff.the state’s words, verbatim · CDSS document, Nov 5, 2025 · control 11-AS-20250903081823

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

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 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.the state’s words, verbatim · CDSS document, Oct 15, 2025 · control 11-AS-20250903081823

The state marks this report as 4 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Allegation investigated: Staff not qualified to give medication.

On 10/01/2025, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent visit to gather information regarding the above allegation. LPA met with Staff and Area Manager Irene Formentera 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), Multidisciplinary Field Notes (08/04/25 - 08/05/25), Visitor Sign-In Sheet (07/31/25 – 08/08/25), and 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. Substantiated 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. 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). Investigation revealed the following: Allegation: Staff not qualified to give medication. Regarding the allegation, “Staff not qualified to give medication,” it is being alleged that Staff #1 was not qualified to administer R1’s medication. Record review of personnel policies revealed that each employee is required to have continuous training and applicable certificates in hospice care and proper handling of medication and required documentation. Medications’ policy and procedure revealed that two hours of hands-on-shadowing training will be provided prior to assisting with the self-administration of medication. Record review of staff training revealed S1 has zero (0) medication training in 2024 and three hours of medication training in 2025. Record review of hospice medication administration record revealed S1 administered R1’s medication on 08/05/25 10:30 AM. Regarding the allegation, “Staff not qualified to give medication,” based on record reviews and interviews, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. Health and Safety Code, Title 22, Division (6) and Chapter (03.2) 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 the Area Manager Irene Formentera. 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. 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). Investigation revealed the following: Regarding the allegation, “Staff did not properly document resident's medications,” it is being alleged that staff could not locate the medication administration record to confirm if medication was administered to Resident #1 on 08/04/25. Record review of Morphine Record revealed medication was administered to R1 on 08/04/25 10:30 PM by S7. Interview with the Area Manager indicated that the record was placed in the back of the R1’s binder. A second medication record revealed medication was administered on 08/05/25 at 10:30 AM and at 11:13 AM. Regarding the allegation, “Staff did not properly document resident's medications,” based on record reviews 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. Allegation: Staff did not ensure resident was provided prescribed medications. Regarding the allegation, “Staff did not ensure resident was provided prescribed medications,” it is being alleged that staff did not provide medication A and B according to the doctor’s order. Record review of Hospice medication profile revealed medication A and B is to be given every hour as needed (08/04/25). Record review of Morphine Record revealed medication was administered to R1 on 08/04/25 10:30 PM by S7. Hospice medication profile revealed medication A and B is to be given every two hours, routinely (08/05/25). Hospice notes indicated that R1 received medication A on 08/05/25 at 10:30 AM and at 11:13 AM. Medication B was given on 08/05/25 at 11:13 AM. Interview with Hospice Agency (Witness #1) indicated that the medication was changed from as needed to routine on 08/05/25 around 10:30 AM. Record review of hospice documents revealed that R1 passed away on 08/05/25 12:13 PM. Regarding the allegation, “Staff did not ensure resident was provided prescribed medications,” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. Continue to LIC9099-C. 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 and a copy of this report was provided to the Area Manager Irene Formentera.the state’s words, verbatim · CDSS document, Oct 1, 2025 · control 11-AS-20250903081823

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.69(a)(2) · Plan of correction due date: Oct 20, 2025

(2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing ... and 4 hours of other training or instruction,... first two weeks of employment. This requirement was not met as evidence by: Based on record review of straff training and MAR, Staff #1 have not completed six hours of medication training prior to administering medication to Resident #1 which posed a potential health risk to resident in care.the state’s words, verbatim · CDSS document, Oct 1, 2025

Plan of correction: The Licensee will provide initial medication training hours to staff who assist with medication and email evidence to regina.cloyd@dss.ca.gov. If needed, the Licensee will also ensure that those who assist with medication will also complete the required renewal hours.

The state marks this report as 8 pages; the online copy we transcribed has 6. You can request the full file from the county licensing office.

Type of visit: Case Management - Annual Continuation

On 01/31/2025, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced – annual continuation inspection and met with Staff. The Area Manager Irene Formentera arrived later. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. First Aid kit was available. Two fire extinguishers, last serviced August 6, 2024 was observed in the living room and in the hallway between rooms #1 and #2. Area Manager tested the carbon monoxide detector and smoke detectors in the house. Both devices were functional. Five staff records were reviewed, 5 out of 5 staff records had current first aid certificates and required criminal record clearances or criminal record exemptions. On 01/30/25, six resident records were reviewed and, six out of six resident records had medical assessments and pre-appraisal or reappraisals. Two residents’ medication was reviewed. On 01/31/2025, four more medical assessments and pre-appraisal were reviewed. Continue to LIC809-C. Deficiencies are being cited based on LPA's observation and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. Resident #5’s (R5) medical assessment reveals a bedridden status. However, R5 is currently in room #5 and it is not approved for bedridden residents. This violation warrants an immediate civil penalty of $500.00 and is hereby assessed, see LIC421IM. An exit interview was conducted, technical assistance provide, Plan of Correction was developed, and a copy of this report and appeals was discussed and left with Area Manager Irene Formentera.the state’s words, verbatim · CDSS document, Jan 31, 2025

Type of visit: Required - 1 Year

On 01/30/2025, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Staff. The Area Manager Irene Formentera arrived later. The facility is licensed to serve twelve (12) non-ambulatory residents age 60 and above. Four residents may be bedridden and rooms 1, 2, & 9 are cleared for bedridden. The facility has a hospice waiver for seven residents. Annual Fees are current. The facility is a single-story family home located in a residential neighborhood. It consists of an attached garage (includes laundry area), front office, eight resident bedrooms (#1 - #8) and one staff bedroom, five bathrooms, dining area, and living room. A shaded area furnished with outdoor patio furniture, including tables and chairs, surrounds the perimeter. Staff 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 inside the facility were clean and 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, and hot water temperature properly measured between 116 F. Continue to LIC809-C. 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 in locked storage cabinet. Six resident records were reviewed. Due to insufficient time, an annual continuation is required. An Exit interview was conducted and a copy of this report was discussed and left with the Area Manager Irene Formentera.the state’s words, verbatim · CDSS document, Jan 30, 2025

Allegation investigated: Facility staff did not provide resident with water resulting in dehydration and hospitalization. Facility staff did not provide resident with adequate amounts of food. Facility staff did not provide resident with adequate care for self-inflicted injury. Facility staff did not seek timely medical attention for resident.

On 03/22/24, at 09:00am, Licensing Program Analysts (LPAs) Perry Scott and Troy Watson conducted a subsequent unannounced visit to the facility and was greeted by Jehn Maric Demafelix, Administrator. LPA explained the purpose of this visit is to gather additional information and deliver findings for the allegations mentioned above. The investigation consisted of the following: An initial complaint visit was completed by LPA Ana Soto on 12/06/2022. A subsequent visit was completed by LPA Perry Scott and Troy Watson on 03/22/2024. LPAs investigated the allegations mentioned in this complaint; and conducted interviews with staff (S1-S5) and residents (R1-R7). Resident/Staff Roster, Admission Agreement, Needs and Service Plan, Face sheets/ID and Emergency Information, Pre-Appraisal, Physician's Report, Doctor’s notes, and Menu for R1 were obtained from the facility. Report continued on LIC9099-C Unsubstantiated The investigation revealed the following: Allegation #1- Facility staff did not provide resident with water resulting in dehydration and hospitalization. The details of the complaint alleged that the facility did not take the time to regularly feed R1 because R1 was admitted to the hospital on 12/2/2022 and was diagnosed with dehydration and weighed only 83lbs. On 03/22/24, from 09:00am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R7) regarding the allegation. R1 could not be interviewed because R1 has passed away. However, a family member of R1 was interviewed. 2 of 5 staff denied the allegation that Facility staff did not provide resident with water resulting in dehydration and hospitalization, while the other three (S3-S5) staff stated that they did not know the resident because the resident was not here when they were hired. S1-S2 stated that the resident was in hospice and had trouble eating and drinking fluids. S1 stated that R1 was on a liquid diet and fed through a syringe, and that they would give R1 ensure (meal supplement) and shakes but R1 would spit it out regularly, even with a syringe. S1 also stated that R1 was given water but that R1 would spit that out as well. S2 stated, “the resident was on hospice and steadily declining there was a problem with getting enough fluids in because R1 would spit out the food as well as water because R1 could not keep anything down for too long; maybe that is why R1 was dehydrated but it wasn’t that we were not giving R1 food and drink, R1 just had a hard time keeping it down. Additionally, in the physician’s report it states that the resident is under non-therapeutic measures which means we are to make the resident as comfortable as possible in the last stages of her life”. LPA interviewed R1-R7 about the allegation that the Facility staff did not provide resident with water resulting in dehydration and hospitalization. 6 of 7 residents that were interviewed stated that the facility gives them enough food and fluids throughout the day and have not had any issues with dehydration. LPA reviewed the preplacement appraisal, dated 04/26/2022, and it states that R1 has difficulty in swallowing and is on a pureed diet. Based on interviews and records reviewed there is insufficient evidence to support the allegation that Facility staff did not provide resident with water resulting in dehydration and hospitalization. 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. Report continued on LIC9099-C Allegation # 2- Facility staff did not provide resident with adequate amounts of food. The details of the complaint alleged that the facility did not feed R1 due to R1s low body weight and that the facility would only feed small portions of food to the resident. On 03/22/24, from 09:00am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R7) regarding the allegation. R1 could not be interviewed because R1 has passed away. However, a family member of R1 was interviewed. 2 of 5 staff denied the allegation that Facility staff did not provide resident with adequate amounts of food, while the other three (S3-S5) staff stated that they did not know the resident because the resident was not here when they were hired. S1-S2 stated that R1 had difficulty eating and drinking and would spit out food and fluids regularly. They repeated that it was not that the facility was not feeding R1, they were, however because of her decline, R1 could not keep any food or fluids in R1’s system. LPA interviewed R1-R7 about the allegation and 6 of 7 residents that were interviewed denied the allegation that Facility staff did not provide resident with adequate amounts of food. Residents stated that they get enough food throughout the day and are satisfied with the care and supervision they are getting from the staff. Based on interviews, there is insufficient evidence to support the allegation that Facility staff did not provide resident with adequate amounts of food. 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. Allegation # 3- Facility staff did not provide resident with adequate care for self-inflicted injury. The details of the complaint alleged that the facility did not change the residents’ dressing and had not cleaned the residents’ wound; causing an infection that happened when R1 had bitten R1s hand. It was reported that the wound was being treated by a wound nurse but when R1 was admitted to the hospital, it was infected. On 03/22/24, from 09:00am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R7) regarding the allegation. R1 could not be interviewed because R1 has passed away. However, a family member of R1 was interviewed. 2 of 5 staff denied the allegation that Facility staff did not provide resident with adequate care for self-inflicted injury, while the other three (S3-S5) staff stated that they did not know the resident because the resident was not here when they were hired. S1-S2 stated that R1 had a history of biting R1’s hand. S1 stated that R1 had bitten R1’s two fingers on R1’s right hand and it had gotten infected. A wound care nurse was hired by St. Teresa Hospice to treat and care for the wound. S1 also stated that on 04/26/22, R1 was admitted to the hospital because R1 kept biting R1’s fingers and R1 would close R1’s mouth to keep them inserted. Report continued on LIC9099-C S2 stated that R1 had a problem with biting R1’s fingers and caused a wound. We let the hospice know and they sent a wound nurse that was treating R1’s injuries. When a family member heard of the problem with biting, the family member wanted to have all R1’s teeth removed but the doctor decided against that. Additionally, S2 stated that we monitored R1 closely, as did the wound care nurse who treated R1’s wounds. LPA interviewed R1-R7 about the allegation and 6 of 7 residents that were interviewed denied the allegation that the Facility staff did not provide resident with adequate care for self-inflicted injury. Residents stated that the staff are responsive and seek medical attention for them if they have injured themselves and take appropriate measures to get them help. LPA reviewed the preplacement appraisal, and it states the resident has a history of grinding R1’s teeth and biting R1’s fingers. Based on interviews, there is insufficient evidence to support the allegation that Facility staff did not provide resident with adequate care for self-inflicted injury. 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. Allegation # 4- Facility staff did not seek timely medical attention for resident. The details of the complaint alleged that the facility did not seek timely medical attention for R1 because when R1 was admitted to the hospital R1 had an infected wound due to a self-inflicted injury and was diagnosed with a urinary infection that is believed to be caused by lack of food and water. On 03/22/24, from 09:00am-02:00pm, LPA interviewed staff (S1-S5) and residents (R1-R7) regarding the allegation. R1 could not be interviewed because R1 has passed away. However, a family member of R1 was interviewed. 2 of 5 staff denied the allegation that Facility staff did not seek timely medical attention for resident, while the other three (S3-S5) staff stated that they did not know the resident because the resident was not here when they were hired. S1-S2 stated that the resident received regular medical attention. There was a hospice care team, wound care nurse, and staff that assisted with the residents’ activities of daily living. LPA reviewed the LIC602A (Physicians Report) that showed the resident was incontinent and had a bladder impairment and bowel impairment, which can cause a urinary tract infection. LPA reviewed the Turning and Repositioning logs which showed the staff were changing R1’s incontinence briefs regularly. LPA interviewed R1-R7 about the allegation and 6 of 7 residents that were interviewed denied the allegation that the Facility staff did not seek timely medical attention for resident. Residents stated that they did not have any issues with the staff getting them timely medical attention when needed. Based on interviews and records reviewed, there is insufficient evidence to support the allegation that Facility staff did not seek timely medical attention for resident. 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. No deficiencies were cited. An exit interview was conducted with Ronald Libiran, Manager, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Apr 4, 2024 · control 11-AS-20221205120407

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced required 1- year visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms and temperature was checked. LPA Bunker met Administrator Jehn Maric Demafelix and explained the purpose of today's Annual Inspection. LPA verified that the facility has an approved mitigation plan report. There are currently four (4) residents in placement. The facility's annual fees are current. 12 Domains in the Infection Control Practices will be observed and reviewed. "I will be using this tool and methods that have been developed to improve the efficiency and accuracy of the Department of Social Services' facility inspections." The facility is a single-story family home located in a residential neighborhood. Which consists of, a living room, dining room, kitchen, 9 bedrooms, 5 bathrooms, laundry area in the garage, attached garage, and an indoor/outdoor activity area. A shaded area furnished with outdoor patio furniture, including tables and chairs. Bedrooms #1-8 are designated as the resident's bedrooms and bedroom #9 is designated as the live-in staff bedroom. During the tour, LPA Bunker observed sanitizer, visitor log, and thermometer at the facility entrance. Logs of daily COVID-19 screening and temperature checks of clients and staff were available and updated. PPE supplies are readily available to staff, and an additional supply of PPE was observed. Sufficient liquid soap, paper goods, cleaning, and disinfecting supplies were observed. LPA observed staff and residents wearing a face covering and social distancing. See continued LIC809-C page 2 Continued LIC809-C page 2 Documents have been diligently posted as mandated on the wall in the dining area. The following Title 22 regulated areas were audited and found to be in compliance: Bedrooms contain the required furniture, and bathrooms are clean and operational. Personal accommodations were observed for safety, privacy, and comfort, including the provision of non-skid surface mats. The kitchen was observed for its ability to prepare and serve food. The food service was reviewed for appropriate quantity and proper storage; there was an ample supply of perishable and nonperishable food. The resident’s medications were reviewed for proper storage, documentation, and system implementation. Medications are securely locked, and records are current and up to date. Common areas observed for the ability to safely serve the needs of the residents, including cleanliness, and clear of any potential hazards to the residents. The first aid kit is fully stocked with manual, smoke, and carbon monoxide detectors were in compliance, the hot water temperature was measured within normal limits at 117.6 degrees Fahrenheit (within the range of 105-120 degrees Fahrenheit). The fire extinguisher is fully charged, adequate linen supply, and the facility's telephones are tested and found to be in working order, The resident's bedroom windows have no sliding window lock with thumbscrews, all exit doors were found to be in compliance, the yard was free of debris hazards, and trash cans were covered. Staff members have undergone training on reporting dependent adult and elder abuse. The facility conducted a fire drill on February 5, 2024 There were no deficiencies cited. Exit interview conducted.the state’s words, verbatim · CDSS document, Feb 8, 2024

Type of visit: Annual/Random

Licensing Program Analyst (LPA) Pamela Bunker conducted an unannounced Annual/Random visit with the primary focus on Infection Control measures and using the new CARE Inspection Tool. Upon arrival at the facility, LPA Bunker conducted a risk assessment. Based on the assessment, the facility is clear of COVID-19 infection. LPA was properly screened for COVID-19 symptoms and temperature was checked. LPA Bunker met with and explained the purpose of today's Annual Inspection. Due to an emergency 24-hour 10-day complaint visit, LPA Bunker had to end today's visit. LPA Bunker will return at a later date to conclude the visit. There were no deficiencies cited. Exit interview conducted.the state’s words, verbatim · CDSS document, Feb 1, 2024