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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320248
Report Date: 04/03/2026
Date Signed: 04/03/2026 12:15:19 PM

Document Has Been Signed on 04/03/2026 12:15 PM - 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
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: 5DATE:
04/03/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:47 AM
MET WITH:Irene FormenteraTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
NARRATIVE
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On 04/03/2026, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced Annual Visit to the facility listed above. LPA met with Administrator, Irene Formentera, and the purpose of today’s visit was explained. LPA was granted entry into the facility.
The facility is licensed to serve 6 non-ambulatory residents aged 60 and over, with an approved hospice waiver for four (4).
Physical Plant/Structure The facility is a two-story structure located in a residential neighborhood. The first floor consists of four (4) resident bedrooms, two (2) bathrooms, living room, dining room, kitchen, two (2) car garage, and outside has a shaded area. The second floor consists of five (5) bedrooms, three (3) bathrooms, and a den. On the shaded back patio, LPA observed a table and chairs available for resident use. All walkways outside the facility were observed clean, clear, and free of debris, hazards, and obstructions. LPA did not observe any bodies of water on the premises.
Bedrooms LPA inspected all residents’ rooms and observed them clean and in good repair. LPA observed resident rooms have the required furniture including a bed(s), dresser(s), nightstand(s), chair(s), and storage space for resident’s personal belongings. LPA observed the beds have the required linens including a mattress cover, fitted sheet, flat sheet, blanket, comforter, and pillows. LPA observed an ample supply of linens. All bedrooms were observed with ample lighting.
Bathrooms LPA inspected the bathrooms and found them to be within Title 22 Regulations. All bathrooms were observed clean and operational. All showers have a non-skid mats, shower chair, and secure safety handrails. LPA observed an ample supply of towels and hygiene products available for residents. The water temperature measured 111.3-degrees and 117.6-degrees Fahrenheit. LPA observed an ample supply of incontinent care supplies stored in resident rooms and an additional supply stored in the garage.
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/03/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CABRILLO GUEST HOME
FACILITY NUMBER: 198320248
VISIT DATE: 04/03/2026
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Kitchen LPA inspected the kitchen and observed it clean and sanitary. LPA observed an ample supply of dishware, cookware, and cutlery. LPA observed that all appliances are operable . LPA observed a 2-day supply of perishable foods, and a 7-day supply of non-perishable foods, properly stored and labeled. LPA observed sharps secured in a locked drawer in the kitchen and are inaccessible to residents. LPA observed cleaning supplies secured in a locked cabinet under the kitchen sink and are inaccessible to residents. The water temperature measured 112.9-degrees Fahrenheit.
Common Areas During the time of visit, LPA observed the facility appropriately furnished. LPA observed the living room has five (5) recliners and a couch to accommodate all residents. LPA observed the dining room has a large table with chairs to accommodate all residents. LPA observed games, reading material, and activities available for resident use. LPA observed all walkways and hallways in the facility are clean, clear and free of hazards and obstructions. All hallways and common rooms were observed with ample lighting. The facility was maintained at a comfortable temperature. LPA observed a fireplace that is screened and inaccessible to residents.
Medications LPA observed Centrally Stored Medications secured in a locked cabinet in the dining room and are inaccessible to residents and visitor. LPA observed medications in their original packaging. LPA reviewed the medication and Medication Administration Record (MAR) for five (5) residents. LPA observed five (5) out of five (5) resident’s medications are consistent with properly documented records.
Files LPA observed resident and staff files secured in a cabinet in the dining room and are inaccessible to residents and visitors. LPA reviewed the files for five (5) residents. LPA observed five (5) residents’ files contain the required documents. LPA reviewed the files for the Administrator and three (3) staff. LPA observed four (4) staff files contain the required clearance, documents, and training. The administrator’s Administrator Certificate, number 7030102740, is valid till 01/11/2027. LPA observed all Licensing Fees are current.
Safety LPA observed the last Fire Prevention Inspection conducted by the Torrance Fire Department was on 01/05/2026. The last Emergency Drill was conducted on 02/31/2026. LPA observed a fully charged fire extinguisher that was last serviced on 08/22/2025. LPA observed smoke and carbon monoxide detectors are operable. LPA observed all exits are indicated with an EXIT sign. LPA received and reviewed the Emergency and Disaster Plan for Residential Care Facilities for the Elderly (LIC610E) was lasted reviewed on 09/03/2025. LPA inspected the First Aid Kit and observed it has the required items and a current manual. LPA received and reviewed the liability insurance through Acord, policy number 0012885504, that is valid till
NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2026
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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: CABRILLO GUEST HOME
FACILITY NUMBER: 198320248
VISIT DATE: 04/03/2026
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03/22/2027. LPA observed all required postings posted in the facility. The facility has a working landline telephone. There are no firearms or ammunition stored on the premises.
Infection Control In the entry of the facility, LPA observed a sanitizing station. LPA observed it consist of a Visitor Sign-In Log and hand sanitizer. LPA observed the required infection control signs posted in the hallway in the facility. LPA observed a 30-supply of Personal Protective Equipment (PPE) stored in the garage.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA did not observe deficiencies therefore no citations were issued at this time.

An exit interview was conducted with Administrator, Irene Formentera, and a copy of this report was provided.

NAME OF LICENSING PROGRAM MANAGER: Eva M Alvarez
NAME OF LICENSING PROGRAM ANALYST: Wendy Gibbs
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2026
LIC809 (FAS) - (06/04)
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