198204399-5-28-2025-11-AS-EMAZ-DHPPF3-20250616111605

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204399
Report Date: 05/28/2025
Date Signed: 05/28/2025 11:19:51 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/25/2024 and conducted by Evaluator Antonine Richard

COMPLAINT CONTROL NUMBER: 11-AS-20241125214045

FACILITY NAME:	VILLA REDONDO CARE HOME		FACILITY NUMBER:	198204399
ADMINISTRATOR:	MARIA BRAVO		FACILITY TYPE:	740
ADDRESS:	237 REDONDO AVENUE		TELEPHONE:	(562) 434-9931
CITY:	LONG BEACH	STATE: CA	ZIP CODE:	90803
CAPACITY:	80	CENSUS: 51	DATE:	05/28/2025
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Jesus Chavez		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff left residents in a soiled diaper for a long period of time.
Staff did not ensure that residents are fed.
Staff verbally abused a resident in care.
Staff threw resident's personal belongings.
Staff made false reports about a resident in care.
Staff prevented the resident from having a visitor while in care.

INVESTIGATION FINDINGS:

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This report serves to clarify investigation findings and is created to supersede the LIC 9099 and LIC 9099-C reports created on 3/21/25. Although this report supersedes the previous report, the complaint investigation findings remain the same. On 05/28/2025, LPA conducted a subsequent complaint visit LPA Richard met with Assistant Administrator Jesus Chavez and explained the purpose of the visit.
On 03/21/2025, at 1:45 pm, Licensing Program Analyst (LPA) Antonine Richard conducted a subsequent complaint investigation at the above facility to address the following allegation(s). LPA met with Administrator Maria Bravo and explained the purpose of the visit. The investigation consisted of the following: On 12/03/24, LPA Richard obtained a copy of the following documents: the facility roster, resident roster, Physician Report, Resident face sheet, Admission agreement, Long Beach Police Department Report Receipt, and interviewed residents and staff members. On 12/03/24, between 10:30 am and 12:00 pm, LPA conducted interviews with residents #1-7(R1-R7), and between 12:00 pm – 2:00 pm, LPA Richard conducted interviews with staff #1-6 (S1-S6).

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025

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

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 11-AS-20241125214045

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: VILLA REDONDO CARE HOME	FACILITY NUMBER: 198204399
	VISIT DATE: 05/28/2025

NARRATIVE

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Allegation #1: Staff left residents in soiled diapers for a long time.

This complaint alleges that residents go hours without being changed and remain in soiled and dirty diapers. On 12/03/2024, between 10:30 am -12:30 pm, LPA Richard interviewed seven (7) residents #1-7 (R1-R7). 6 out of 7of denied the allegation and stated that they are changed every one to two hours daily. LPA interviewed six staff #1-6 (S1-S6). 6 out of 6 denied the allegation and stated that all the residents are being changed every 2 hours, sometimes sooner if an accident happened before or after the time to change passed. LPA interviewed Administrator #1 (A1), who stated that the residents are checked every 1 - 2 hours. Record review of changing schedule (dated 11/01/24 to 11/30/24), has a schedule of all the name of residents who wears a diaper on when to be changed. LPA Richard attempted to interview R1, who declined to answer any of the questions asked.

Regarding the allegation: Staff leave residents soiled for an extended period, based on 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 #2: Staff did not ensure that residents were fed.

This complaint alleges that staff did not ensure residents were being fed and not being woken up to eat. LPA interviewed Administrator #1 (A1), Maria Bravo, about the allegation. A1 stated that meals are served on the third floor at 8 am, 11:30 am, and 4:30 pm like clockwork. If a resident does not come to eat in the dining room, the staff would go and knock on the resident's door and ask if the residents want to have breakfast brought to the room. The Administrator stated that the staff serves a well-balanced meal with a variety of food options to choose from each day. On 12/03/2024, between 10:30 am - 12:30 pm, LPA Richard interviewed seven residents #1-7 (R1-R7). 6 out of 7 denied the allegation and stated that the facility would go to their room and knock on the door to make sure they had breakfast, lunch, and dinner in the dining room. They also stated that they did not have any problem with the food.

Report continued LIC9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 11-AS-20241125214045

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: VILLA REDONDO CARE HOME	FACILITY NUMBER: 198204399
	VISIT DATE: 05/28/2025

NARRATIVE

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On 12/03/2024, between 12:30 pm and 2:00 Pm, LPA Richard interviewed six (6) staff #1-6 (S1-S6) 6 out of 6 stated that they make sure the residents eat every day, if the residents did not want to eat the staff would talk to them to found out if they wanted to eat something else. LPA reviewed the facility menu for the week and observed a variety of food options listed on the menu. LPA Richard attempted to interview R1, who declined to answer questions when asked.

Regarding the allegation, Staff did not ensure that residents were fed, Based on interviews and records review, 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 #3: Staff verbally abused the resident in care.

This complaint alleges that the facility staff verbally abused residents due to retaliation if they reported the abuse. On 12/03/2024, between 12:00 pm and 2:00 pm, LPA interviewed Administrator #1 (A1) about the allegation. A1 denied that the staff ever verbally abused the clients. (A1) stated that they respect all the clients, and they go out of their way to help their clients because they want the clients to feel comfortable and have the freedom if they were in their own homes. On 12/03/24, between 10:30 am -12:00 pm, LPA interviewed seven (7) residents (R1-R7), 6 out of 7 stated that since they have been living there, the staff had never verbally abused them. On 12/03/24, between 12:00 pm – and 2:00 pm, LPA interviewed six (6) staff (S1-S6), 6 out of 6 denied the allegation and stated that they had never witnessed other staff verbally abuse the clients, on the contrary, the residents were the ones who verbally abused and threatened the staff. The staff also stated that they have received training regarding clients’ rights. LPA attempted to interview R1, who declined to answer any of the questions asked.

Regarding the allegation, Staff verbally abused a resident in care. Based on 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.

Report continued LIC9099-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 11-AS-20241125214045

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: VILLA REDONDO CARE HOME	FACILITY NUMBER: 198204399
	VISIT DATE: 05/28/2025

NARRATIVE

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Allegation #4: Staff threw the resident's personal belongings.

This complaint alleges that staff entered the resident's room and threw the resident's clothes and shoes on the floor. The department interviewed Administrator #1(A1), who stated that the staff never entered the resident's room and threw their clothes and shoes on the floor because the staff knows the residents have rights, and the staff needs permission from the resident to even throw away expired food inside the refrigerator. On 12/ 03/24, between 10:30 am -12:00 pm, LPA interviewed seven (7) residents #1-7 (R1-R7). 5 out of 7 stated that the staff never threw their clothes on the floor. The staff always asked them if they could throw away the expired food inside the refrigerator when cleaning the room. On 12/03/24, between 12:00 pm- 2:00 pm, LPA interviewed six (6) staff #S (S1-S6), and 6 out of 6 stated that the resident has the right to say no to us and we cannot throw away their stuff. The staff also stated that they have not received a complaint from the resident in care that the facility staff threw away their stuff. LPA attempted to interview R1, who declined to answer any of the questions asked.

Regarding the allegation, Staff threw the president’s personal belongings. Based on 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 #5: Staff made a false report about a resident in care.

This complaint alleges that the staff made a false report about a resident, resulting in the facility calling law enforcement and filing false reports to get the client arrested. On 12/03/24, between 12:00 pm – 2:00 pm, LPA interviewed administrator #1 (A1), who stated that the facility did call law enforcement for the resident it was resident, who was choking one of our residents. When police arrived, the victim didn’t want to press battery charges. On 12/03/24, between 12:00 – 2:00 pm, LPA Records reviewed of law enforcement report receipt dated 11/23/24 and confirmed that law enforcement did receive a call from the facility about an altercation. The department interviewed seven (7) residents #1-7 (R1-R7), and 6 out of 7 stated that they didn’t know anything about the staff making false reports about them; all they knew was that the staff always tried to help when there was fighting among the residents.

Report Continues, see LIC9099C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 11-AS-20241125214045

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: VILLA REDONDO CARE HOME	FACILITY NUMBER: 198204399
	VISIT DATE: 05/28/2025

NARRATIVE

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LPA Richard attempted to interview R1, who declined to answer any of the questions asked.

Regarding the allegation, Staff made a false report about a resident in care. Based on interviews, and record reviews, 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 #6: Staff prevented the resident from having a visitor in care.

This complaint alleges that the staff is not allowing the residents' visitors to visit the residents and stated that the resident is not there. On 12/03/24, between 12:00 pm -2:00 pm, LPA interviewed administrator #1, Maria Bravo (A1), who denied the allegation. A1 stated that all the residents have visitors seven days a week. If the residents share rooms, they cannot have visitors inside the room, unless it’s a private room. On 12/03/24 between 12:00 pm - 2:00 pm, LPA interviewed the facility front desk (S2) and stated that most of the residents have visitors, and they must sign in and out. Sometimes, the family members refuse to sign in and out, but we never deny them entry. On 12/03/24, between 10:30 am -12:00 pm, LPA interviewed seven (7) residents (R1-R7), and 6 out of 7 stated that they do have family members visit them; they all know that if they have a roommate, they cannot have visitors inside their room. On 12/03/24, between 12:00 pm and 2:00 pm, LPA interviewed six (6) staff (S1-S6), all denied the allegation. LPA Richard attempted to interview R1, who declined to answer any questions asked. Records reviewed, dated 09/30/2024, showed that most of the residents had visitors at the facility. During the visit to the facility on 12/03/2024, the department observed several family members visiting the residents; some of them signed in, and some of them refused to sign in. Based on interviews, observations, and records reviewed, there was not enough sufficient evidence to support the allegation. 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 deemed unsubstantiated.

No deficiencies were cited. An exit interview was conducted, and a copy of this report was provided to the Assistant Administrator Jesus Chavez.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Antonine Richard
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2025

LIC9099 (FAS) - (06/04)

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