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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198320248
Report Date: 05/15/2025
Date Signed: 05/15/2025 04:58:19 PM

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
05/07/2025 and conducted by Evaluator Regina Cloyd
COMPLAINT CONTROL NUMBER: 11-AS-20250507084214
FACILITY NAME:CABRILLO GUEST HOMEFACILITY NUMBER:
198320248
ADMINISTRATOR:IRENE FORMENTERAFACILITY TYPE:
740
ADDRESS:23731 CABRILLO AVENUETELEPHONE:
(310) 325-7610
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY:6CENSUS: 5DATE:
05/15/2025
UNANNOUNCEDTIME BEGAN:
08:39 AM
MET WITH:Irene FormenteraTIME COMPLETED:
05:15 PM
ALLEGATION(S):
1
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5
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9
Staff are not able to meet the resident's needs.
Staff are not following doctor's orders when administering medication.
INVESTIGATION FINDINGS:
1
2
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4
5
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9
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On 05/15/2025 Licensing Program Analyst (LPA) Regina Cloyd conducted an initial visit on to gather information regarding the above allegation(s). LPA met with Area Manager Irene Formentera and the purpose of the visit was explained.

Investigation consisted of the following : On 05/15/2025, LPA reviewed Personnel Report, Register of Residents, Resident Records (Residents #1 – 5), Resident’s (1 – 5) May Medication Administration Record (MAR), Resident’s (1 – 4) Medication Profiles, observed medication for Residents #1 – 5, and interviewed Residents 1 - 4, Area Manager, and two Caregivers.

Investigation revealed the following:


LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
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 2
Control Number 11-AS-20250507084214
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: CABRILLO GUEST HOME
FACILITY NUMBER: 198320248
VISIT DATE: 05/15/2025
NARRATIVE
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Investigation revealed the following:

Allegation: Staff are not able to meet the resident's needs.

Record review revealed four out of five residents have a complete Plan of Care/Needs and Services Plan. Four out of four resident interviews indicated that staff can meet their needs. LPA observed that all four residents was alert. Staff interviews indicated that they are able to meet the needs of the residents. Interview with S1 indicated that care services are based on the physician’s report and discussions with the residents and their families. S1 also indicated that care services are adjusted based on staff observations of the residents and discussions with the residents and/or their families.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

Allegation: Staff are not following doctor's orders when administering medication

Record review of May’s Medication Administration Records and Physician’s Medication Profile are consistent and medication is administered according to doctor’s orders for four out of four residents. Four out of four resident interviews indicated that staff has not made any medication errors. Three out of three staff interviews indicated medication is administered according to doctor’s orders.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

No deficiencies were issued.

An exit interview was conducted, technical assistance provided, and a copy of this report was provided to the Area Manager Irene Formentera.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2