<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609367
Report Date: 12/20/2022
Date Signed: 12/20/2022 04:59:27 PM


Document Has Been Signed on 12/20/2022 04:59 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:SANTA MONICA HOME & CARE 4FACILITY NUMBER:
197609367
ADMINISTRATOR:GARY STRATHEARNFACILITY TYPE:
740
ADDRESS:910 10TH ST UNIT ATELEPHONE:
(310) 576-0044
CITY:SANTA MONICASTATE: CAZIP CODE:
90403
CAPACITY:4CENSUS: DATE:
12/20/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Administrator, Gary Strathearn and Jennifer BlockTIME COMPLETED:
05:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/20/22, Licensing Program Analyst (LPA) Antonia conducted a case management inspection visit at this facility. LPA was greeted by Administrators Gary Strathearn and Jennifer Block and explained the purpose of the visit. LPA was at this facility in conjunction with complaint # 11-AS-20221216140503

During the visit LPA was made aware the facility failed to adhere to regulations Title 22 Section 87355. LPA identified and confirmed S#1 does not have a Criminal Record Clearance and S#2 - S#3 did not have an association to the facility.Staff #1 (S1 ) work at this facility caring for residents without proof of Criminal Record Clearance. Administrator Jennifer, stated, "S#1 was will be send home and will not return to work until obtained a Criminal Record Clearance, or a Criminal Record Exemption as required by (CCLD) Community Care Licensing Division. Staff #2 will not work until obtained association to the facility. Staff #3 will only work at the Santa Monica Home & Care #1. Based on the information gathered, the licensee violated the California Code Regulations (CCR) of Title 22 sections 87355 Division 6 Chapter 8.


LPA was also informed that several positive COVID -19 case incidents were not reported to CCLD. In relation to R#1 based on the information gather Licensee violated the California Code Regulations "CCR" of Title 22 sections 87355 and 87211 Division 6 Chapter 8.


Citation is issued, civil penalties assessed, and exit interview conducted and a copy was provided to Administrator Jennifer Block.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 12/20/2022 04:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: SANTA MONICA HOME & CARE 4
FACILITY NUMBER: 197609367

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied: Appeal Not Submitted Timely
Type A
12/20/2022
Section Cited
CCR
87355(e)(2)

1
2
3
4
5
6
7
87355(e)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2)Request a transfer of a criminal record clearance as specified in Section 87355(c)
1
2
3
4
5
6
7
Administrator will adhere to title 22 and will ensure that all staff are criminal record reviewed and approved.

The administrator will remove all staff that are not criminal clearanced approval.
8
9
10
11
12
13
14
Based on observation and interviews, the licensee did not comply with the section cited above. The facility did not have approved criminal clearance for S#1 - S#3.This violation poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Type B
12/20/2022
Section Cited
CCR87211(a)(B)(D)

1
2
3
4
5
6
7
87211(a)(B)(D) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department... (B) Any serious injury... occurring while the resident is under facility supervision. (D) Any incident which threatens the welfare, safety or health of any resident...
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator will review Title 22 Sec. 87211 and agreed to provide training to staff pertaining to CCLD reporting Requirements. Licensee will provide to LPA a sign-in sheet with staff signatures as proof that staff attended training by the POC due date: 01/16/2023.
8
9
10
11
12
13
14
Based on record reviews and interviews, the licensee did not comply with the section cited above. The facility failed to submit written report positive COVID -19 cases in the facility. This violation poses an potential health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 12/20/2022 04:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754


FACILITY NAME: SANTA MONICA HOME & CARE 4
FACILITY NUMBER: 197609367

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/20/2022
Section Cited
CCR
87355(e)(1)

1
2
3
4
5
6
7
87355(e)(1) Criminal Record Clearance:(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working... in a licensed facility: (1) Obtain a California...criminal record exemption as required by the Department
1
2
3
4
5
6
7
Administrator will adhere to title 22 and will ensure that all staff are criminal record reviewed and approved.

The administrator will remove all staff that are not criminal clearanced approval.
8
9
10
11
12
13
14
Based on observation and interviews, the licensee did not comply with the section cited above. The facility did not have approved criminal clearance for S#1.This violation poses an immediate health, safety or personal rights risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Antonia AlvizarTELEPHONE: (323) 516-4092
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3