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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320248
Report Date: 03/06/2025
Date Signed: 03/06/2025 11:05:42 AM

Document Has Been Signed on 03/06/2025 11:05 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:CABRILLO GUEST HOMEFACILITY NUMBER:
198320248
ADMINISTRATOR/
DIRECTOR:		IRENE FORMENTERAFACILITY TYPE:
740
ADDRESS:23731 CABRILLO AVENUETELEPHONE:
(310) 325-7610
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 4DATE:
03/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:19 AM
MET WITH:Irene Formentera, Administrator TIME VISIT/
INSPECTION COMPLETED:
11:15 AM
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On 03/06/2025 at 08:19am, Licensing Program Analyst (LPA) Zina Brown conducted an unannounced one- year inspection. LPA met with COO JM Demafelix and Irene Formentera, Administrator and the purpose of the visit was discussed. Facility is licensed to serve 6 non- ambulatory residents and an approved hospice waiver for 4 resident from age range 60 and over. Two (2) of the residents are diagnosed with dementia, one (1) resident is receiving home health and one (1) of the residents is hospice & palliative care services. The facility does not handle any of the residents’ money. The facility balance fees are $0. The liability insurance is with James River Insurance Company with each occurrence is $1,000,000 and general aggregate is $3,000,000 which is valid from 03/22/2024 - 03/22/2025.

The facility is a 2-story house located in a residential neighborhood and consists of four (4) bedrooms for the residents, two (2) bathrooms and a two (2) car garage, which houses a washer, dryer and an additional refrigerator on the first floor; the second floor consists of five (5) bedrooms, three (3) bathrooms and a den. The home also consists of a living room, dining room, and kitchen on the first floor. The facility is clean, sanitary, and in good repair.

Between the hours of 10:25 am - 10:55 am, LPA toured the resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. 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, water temperature measured between 122.1F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards; doorways were free of obstructions.

Report continues of LIC 809-C.

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2025
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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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: CABRILLO GUEST HOME
FACILITY NUMBER: 198320248
VISIT DATE: 03/06/2025
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Between the hours of 9:20am - 10:15 am, LPA conducted a records review of (5) client records, (5) staff records, (0) clients Personal & Incidental Records and reviewed the facility disaster plan (last fire drill was conducted on 03/02/2025 and earthquake drill was conducted on 02/14/2025. LPA reviewed (4) Client Medication Administration Records and did not observed any discrepancies at the time of visit. All client & Staff records were complete.

Kitchen was checked and observed to be within Title 22 regulations. Perishable and non-perishable food supply was checked. All cleaning solutions, hazardous items, and medications were securely locked and inaccessible to residents. Smoke detectors were working properly, and fire extinguisher was fully charged. Carbon monoxide detector was operational. First Aid kit was available. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There are no security bars or weapons on the premises.

During todays visit LPA did not observe any deficiencies.

An exit interview was conducted Irene Formentera (Administrator).

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Zina Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2025
LIC809 (FAS) - (06/04)
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