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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204399
Report Date: 12/05/2024
Date Signed: 12/05/2024 10:43:35 AM

Document Has Been Signed on 12/05/2024 10:43 AM - 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:VILLA REDONDO CARE HOMEFACILITY NUMBER:
198204399
ADMINISTRATOR/
DIRECTOR:		MARIA BRAVOFACILITY TYPE:
740
ADDRESS:237 REDONDO AVENUETELEPHONE:
(562) 434-9931
CITY:LONG BEACHSTATE: CAZIP CODE:
90803
CAPACITY: 80CENSUS: 65DATE:
12/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:12 AM
MET WITH: Maria Bravo, AdministratorTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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On December 05, 2024 at 8:10 am Licensing Program Analyst (LPA) Zina Brown conducted an unannounced health and safety check to follow up on a incident that occurred on November 27, 2024.

During today visit we met with Maria Bravo (Administrator) and explained the purpose of the visit.

During today's visit, LPA conducted interviews with staff and clients. LPA also reviewed and collected the following:
  • LIC 500: Personnel Report
  • LIC 601: Identification and Emergency Information (Resident #1 - Resident #2)
  • LIC 602: Physician's Report for Community Care Facilities (Resident #1 - Resident #2)
  • LIC 625: Appraisal/Needs and Services Plan (Resident #1 - Resident #2)
  • LIC 624: Unusual Incident/Injury Report
  • Medication list for (Resident #1 & Resident #2)
  • Reviewed and received video surveillance footage of the incident that occurred on 11/27/2024
Due to insufficient information available at this time a further investigation is needed.

A exit interview was conducted with Maria Bravo (Administrator), and a copy of this report was provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2024
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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