198204399-8-6-2025-11-AS-RORN-DKWUWQ-20250826155708

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204399
Report Date: 08/06/2025
Date Signed: 08/06/2025 10:58:29 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
07/18/2025 and conducted by Evaluator Elvira Gonzalez

COMPLAINT CONTROL NUMBER: 11-AS-20250718154112

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; 80	CENSUS: 53	DATE:	08/06/2025
		UNANNOUNCED	TIME BEGAN:	08:01 AM
MET WITH:	Jesus Chavez		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff do not respond to residents' calls for assistance in a timely manner.
Staff do not ensure residents’ incontinence needs are being met.
Staff do not ensure residents' showering needs are being met.
Staff do not ensure facility remains free of bad odors.
Staff are mismanaging residents' medication .

INVESTIGATION FINDINGS:

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On 08/06/25, Licensing Program Analyst (LPA) Elvira Gonzalez conducted an unannounced complaint visit to investigate the above-mentioned allegations. LPA met with Assistant Administrator, Jesus Chavez, and explained the purpose of the visit. LPA was granted access to the facility.

The investigation consisted of the following: On 07/24/25, LPA reviewed resident files and requested and reviewed the following documents: staff roster, resident roster, call light logs for 06/01/25 through 07/24/25, shower skin monitoring forms for various residents, and residents shower schedule. LPA conducted interviews with staff #1-#6 (S1-S6), and residents #1-#3 (R1-R3). Additionally, LPA and Assistant Administrator, Jesus Chavez toured the facility, and inspected resident rooms, bathrooms, and common areas. On 07/25/25, LPA received Medication Administration Record (MAR) for the months of June and July 2025 R1-R3 and R8, conducted interviews with residents #4-#7 (R4-R7) and attempted to interview residents #8-#9 (R8-R9). Furthermore, on 08/06/25, LPA Gonzalez and Assistant Administrator, Jesus Chavez, inspected resident bedrooms #208 and #319.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025

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-20250718154112

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: 08/06/2025

NARRATIVE

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The investigation revealed the following: Regarding the allegation “Staff do not respond to residents' calls for assistance in a timely manner,” it is alleged that staff is taking a long time to respond to a resident’s call light request. On 07/24/25, between 12:10 PM and 1:45 PM, LPA Gonzalez conducted interviews with S1-S6. Of those interviewed, 6 out of 6 staff denied the allegation. 5 out of 6 staff stated that they respond to a residents call light request within 5 minutes.

On 07/24/25, between 1:55 PM and 3:30 PM, LPA conducted interviews with R1-R3, and on 07/25/25 between 1:30 PM and 2:45 PM, LPA conducted interviews with R4-R7 and attempted to interview R8-R9. Of those interviewed, 6 out of 7 residents said staff responds to their call light request in a timely manner. 7 out of 7 residents stated that there is enough staff to meet their needs.

On 08/06/25, LPA Gonzalez reviewed the Personnel Roster (Dated: 07/01/2025) and observed that there is sufficient staff to meet the needs of the residents. Additionally, on 08/06/25, LPA Gonzalez inspected resident bedrooms #208 and #319 and observed call buttons to be in operable condition. ¬LPA Gonzalez observed Assistant Administrator, Jesus Chavez pull the call light cord and found that the facility staff responded in less than four minutes.

Based on record review, interviews, and observations, 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.

Regarding the allegation “Staff do not ensure residents’ incontinence needs are being met,” it is alleged that residents are left in soiled briefs for extended periods of time. On 07/24/25, between 12:10 PM and 1:45 PM, LPA Gonzalez conducted interviews with S1-S6. Of those interviewed, 6 out of 6 staff denied the allegation. 6 out of 6 staff stated that no residents is left in the same briefs for 24 hours or longer. 5 out of 6 staff stated that residents briefs are changed every 2 hours.

Continued on LIC9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 11-AS-20250718154112

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: 08/06/2025

NARRATIVE

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On 07/24/25, between 1:55 PM and 3:30 PM, LPA conducted interviews with R1-R3, and on 07/25/25 between 1:30 PM and 2:45 PM, LPA conducted interviews with R4-R8 and attempted to interview R8-R9. Of those interviewed, 5 out of 7 residents stated that they have not been left in soiled briefs for an extended period of time, and 2 out of 7 residents stated that they don’t require toileting assistance. 5 out of 7 residents stated that staff has not left a resident in the same briefs for 24 hours or longer, and 2 out of 7 residents stated that they didn’t know if a resident has been left in the same briefs for 24 hours or longer.

Based on record review, interviews, and observations, 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.

Regarding the allegation, “Staff do not ensure residents' showering needs are being met,” it is alleged that there are several residents who haven’t been showered in a month or longer. On 07/24/25, between 12:10 PM and 1:45 PM, LPA Gonzalez conducted interviews with S1-S6. Of those interviewed, 6 out of 6 staff stated that resident’s bathing needs are being met. S2 stated that the residents get two showers a week and the days vary depending on their schedule, hospice residents get one from staff and two from the hospice agency, and that they just check on their independent residents and make sure they are showering and ask them if they need assistance. S1 stated that if a resident refuses, staff will attempt three times and then document it on their skin monitoring form. The staff will sign that form after 3 attempts and so will the resident.

On 07/24/25, between 1:55 PM and 3:30 PM, LPA conducted interviews with R1-R3, and on 07/25/25 between 1:30 PM and 2:45 PM, LPA conducted interviews with R4-R7 and attempted to interview R8-R9. Of those interviewed, 4 out of 7 residents said their bathing needs are being met, and 3 out 7 residents said they don’t require any bathing assistance. 4 out of 7 residents stated they get at least 2 showers a week, and 3 out of 7 residents said they don’t require any bathing assistance. 4 out of 7 residents said no resident has gone 24 hours or more without bathing, and 3 out of 7 residents said they didn’t know if a resident has gone 24 hours or more without bathing. 6 out of 7 residents said they are satisfied with the services provided to them.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 11-AS-20250718154112

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: 08/06/2025

NARRATIVE

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On 08/05/25 LPA conducted a review of the shower schedule and observed documentation indicating showers are done twice a week, LPA also observed documented refusals from residents on the facility’s skin monitoring forms.

Based on record review, interviews, and observations, 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.

Regarding the allegation, “Staff do not ensure facility remains free of bad odors,” it is alleged that a resident’s room has a very bad odor. On 07/24/25, between 12:10 PM and 1:45 PM, LPA Gonzalez conducted interviews with S1-S6. Of those interviewed, 5 out of 6 staff stated that a resident messes with their catheter and it causes urine to spill and get on the floor. 6 out of 6 staff said that housekeeping deep cleans resident’s room once a week, and as needed. 4 out of 6 staff denied that a resident’s room has a bad odor, and 2 out 6 staff said it does have a bad odor.

On 07/24/25, between 1:55 PM and 3:30 PM, LPA conducted interviews with R1-R3, and on 07/25/25 between 1:30 PM and 2:45 PM, LPA conducted interviews with R4-R7 and attempted to interview R8-R9. Of those interviewed, 1 resident stated they have had accidents with their catheter which caused urine to spill on the floor, and that staff does a very good job at keeping their room clean. 6 out of 7 residents said they don’t know if a resident’s room has bad odor. 7 out of 7 residents stated that housekeeping cleans their room at least once a week.

Based on record review, interviews, and observations, 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.

Continued on LIC9099-C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 11-AS-20250718154112

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: 08/06/2025

NARRATIVE

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Regarding the allegation, “Staff are mismanaging residents' medication,” it is alleged that residents are missing their medications due to staff not ordering refills timely. On 07/24/25, between 12:10 PM and 1:45 PM, LPA Gonzalez conducted interviews with S1-S6. Of those interviewed, 4 out of 6 staff denied the allegation, and 2 out of 6 staff said they did not know if residents are missing their medications due to staff not ordering refills timely. 5 out of 6 staff said that staff administers the resident’s medication on time and as prescribed, and 1 out of 6 staff said they did not know if staff administers the resident’s medication on time and as prescribed. S2 stated that a resident has asked staff for their PRN medication, but sometimes they are out of it. often. S2 stated that it’s an issue because that certain medication is controlled, and requires for the resident to be seen by their doctor before they prescribe a refill. S2 stated that staff will call the doctor a week before the medication runs out, but the doctor won’t come until a week later to see the resident, which will cause a delay in the resident receiving the medication.

On 07/24/25, between 1:55 PM and 3:30 PM, LPA conducted interviews with R1-R3, and on 07/25/25 between 1:30 PM and 2:45 PM, LPA conducted interviews with R4-R7 and attempted to interview R8-R9. Of those interviewed, 7 out 7 residents said they receive their medications on time and as prescribed by their physician. 7 out of 7 residents said they have not missed any medication due to the medication not being available.

LPA Gonzalez conducted a record review of the MARs for the months of June and July 2025 for R1-R3 and R8 and did not observe any discrepancies or mismanaging of residents’ medication.

Based on observation, interviews conducted, and a review of records, the department did not find 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 Unsubstantiated.

No deficiencies were cited during this investigation.

An exit interview was conducted with Assistant Administrator, Jesus Chavez, and a copy of this report and appeal rights was provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Elvira Gonzalez
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2025

LIC9099 (FAS) - (06/04)

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