198204399-9-17-2026-11-AS-UCOL-DY5MZV-20260921100343

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204399
Report Date: 09/17/2026
Date Signed: 09/17/2026 10:56:57 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/30/2026 and conducted by Evaluator Socorro Leandro

COMPLAINT CONTROL NUMBER: 11-AS-20260130115423

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: 56	DATE:	09/17/2026
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator - Jesus Chavez		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Resident is malnourished due to staff neglect

INVESTIGATION FINDINGS:

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On 09/17/2026, Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced subsequent complaint investigation visit regarding the allegation listed above. LPA met with the Administrator, Jesus Chavez, and the purpose of the visit was explained. LPA was granted entry to the facility.

Investigation consisted of the following:

On 02/05/2026, Staff 1 (S1) to Staff 7 (S7) were interviewed and facility records were gathered. On 09/16/2026, records were reviewed, interviews and observations were conducted. Interviews conducted consisted of Resident 1 (R1) to Resident 7 (R7). Lunchtime was observed. Records reviewed consisted of Resident Rosters, Employee Rosters, Meal Menus from 10/09/2025 to 01/31/2026. On 09/17/2026, Resident 1’s (R1) records were reviewed.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026

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 4

Control Number 11-AS-20260130115423

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VILLA REDONDO CARE HOME	FACILITY NUMBER: 198204399
	VISIT DATE: 09/17/2026

NARRATIVE

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Investigation revealed the following:

Allegation: “Resident is malnourished due to staff neglect”, it is being alleged that R1 has gone through significant weight loss due to staff neglect.

Interviews conducted with S1 to S7 revealed the following: 7 out of 7 staff denied the allegation.

Interviews conducted with R1 to R7 revealed the following: 7 out of 7 residents denied the allegation, additionally, residents indicated that they have not witnessed a resident malnourished in the facility. Moreover, R1 indicated that the facility provides them with breakfast, lunch, and dinner and they attempt to eat everything off their plate, furthermore, if they were to request for seconds then the facility would provide them with seconds.

R1’s records reviewed revealed the following:

On 08/25/2025, R1’s Medical Assessment stated that they weighed 92 pounds (lbs.); had a special diet of fortified mechanical soft chopped and regular liquids; and was able to feed self with “needs set up assistance.”

On 08/28/2025, R1 signed the Admission Agreement.

On 08/21/2025, R1 had their Individualized Service Plan, and the document does not mention dietary needs. On 08/29/2025, R1 had their Preplacement Appraisal and the records stated that “Resident is able to feed self but needs encouraging.”

On 01/07/2026, R1 had a meeting with a registered dietitian regarding the meals in the facility and food preferences.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20260130115423

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VILLA REDONDO CARE HOME	FACILITY NUMBER: 198204399
	VISIT DATE: 09/17/2026

NARRATIVE

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On 01/21/2026, R1 had their Medical Assessment and the document stated that R1 does not have a special diet and is able to feed self.

On 09/14/2026, R1 had their Preplacement Appraisal Information, and the document stated the following “mechanical soft chopped texture,” does not have a special diet nor requires assistance with eating.

R1’s Vital Records reviewed revealed the following: On 11/10/2025, R1 weighed 80.4 lbs.; on 12/12/2025 R1 weighed 79 lbs.; on 01/22/2026 R1 weighed 78.2 lbs.; on 02/16/2026 R1 weighed 76.2 lbs.; on 06/01/2026 R1 weighed 70.2 lbs.; on 08/10/2026 R1 weighed 68.8 lbs.

Records reviewed of facility staff contacting R1’s medical providers revealed the following: On 10/27/2025, facility requested supplements for R1. On 11/25/2025, facility informed medical provider that R1’s medical assessment stated that R1 weighed 92 lbs. and two weeks ago R1 weighed 80.4 lbs., moreover, staff stated “I did request an order for ensure, anything else you would like to advise?” On 12/02/2025, facility discussed R1’s medical action plan with medical provider. On 12/12/2025, facility discussed R1’s current weight with medical provider and received R1’s “GI referral, abdominal US results, and most recent labs.” On 01/07/2026, R1 had an appointment with a Gastroenterologist and the medical provider requested an order for labs. On 01/28/2026, the facility communicated with R1’s physician regarding food consumption.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 11-AS-20260130115423

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: VILLA REDONDO CARE HOME	FACILITY NUMBER: 198204399
	VISIT DATE: 09/17/2026

NARRATIVE

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Records reviewed of R1’s Daily Logs revealed the following: On 11/18/2025, facility contacted physician for R1. On 11/26/2025, facility staff had a conversation with W1 regarding R1’s weight loss. On 12/02/2025, physician sent referral for weight loss. On 01/19/2026, R1 had an appointment with a Gastroenterologist. On 01/21/2026, R1 had a conversation with a Consultant Dietitian about nutrition. On 01/23/2026, W1 refused for R1 to go to their medical appointment and changed R1’s medical providers. On 01/28/2026, the facility requested R1’s medical assessment to be updated. On 02/06/2026, the facility requested R1’s medical assessment to be updated. On 06/01/2026, the facility contacted R1’s physician to get their medical assessment updated. On 07/01/2026, the facility contacted R1’s physician to get their medical assessment updated. On 08/11/2026, R1 under a new physician and they have upcoming medical appointment to update the medical assessment. On 09/02/206, medical professionals came to the facility to see R1 but they were not in the facility. On 09/03/2026, R1 received comprehensive lab work. On 09/11/2026, the facility received R1’s lab results. On 09/16/2026, the facility sent R1’s new physician weight records for the past year to review and scheduled an appointment for 09/21/2026.

Unsubstantiated: 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.

An exit interview was conducted, and a copy of this report was left with the Administrator, Jesus Chavez.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Socorro Leandro
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2026

LIC9099 (FAS) - (06/04)

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