197608376-4-8-2026-11-AS-RCLD-DSXW5Y-20260408165956

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608376
Report Date: 04/08/2026
Date Signed: 04/08/2026 05:00:23 PM

Document Has Been Signed on 04/08/2026 05:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME:	REDONDO BEACH ELDERLY HOME		FACILITY NUMBER:	197608376
ADMINISTRATOR/ DIRECTOR:	JEHN MARIC DEMAFELIX		FACILITY TYPE:	740
ADDRESS:	18312 MANSEL AVENUE		TELEPHONE:	(310) 371-7193
CITY:	REDONDO BEACH	STATE: CA	ZIP CODE:	90278
CAPACITY: 12		CENSUS: 10	DATE:	04/08/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:16 AM
MET WITH:	Irene Formentera		TIME VISIT/ INSPECTION COMPLETED:	05:15 PM

NARRATIVE

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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.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Regina Cloyd
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 04/08/2026 05:00 PM - It Cannot Be Edited

Created By: Regina Cloyd On 04/08/2026 at 04:20 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: REDONDO BEACH ELDERLY HOME	FACILITY NUMBER: 197608376
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/08/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in four restrooms which poses an immediate safety risk to persons in care. 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.
	POC Due Date: 04/09/2026
	Plan of Correction
1 2 3 4	The Administrator will submit a plan of correction, including water temperature log, to regina.cloyd@dss.ca.gov by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:

	Regina Cloyd
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: REDONDO BEACH ELDERLY HOME	FACILITY NUMBER: 197608376
	VISIT DATE: 04/08/2026

NARRATIVE

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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.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Regina Cloyd
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: REDONDO BEACH ELDERLY HOME	FACILITY NUMBER: 197608376
	VISIT DATE: 04/08/2026

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	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.

NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Regina Cloyd
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/08/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2026

LIC809 (FAS) - (06/04)

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