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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198205144
Report Date: 07/11/2022
Date Signed: 07/13/2022 01:54:28 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
12/30/2019 and conducted by Evaluator Lourdes Montoya
COMPLAINT CONTROL NUMBER: 11-AS-20191230164628
FACILITY NAME:SANTA FE HOME CARE HOMESFACILITY NUMBER:
198205144
ADMINISTRATOR:ANGELIQUE GRADNEYFACILITY TYPE:
740
ADDRESS:2340 SANTA FE AVENUETELEPHONE:
(310) 831-2085
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY:6CENSUS: 3DATE:
07/11/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:CATHERINE ESPINOTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Resident has multiple pressure injuires.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Lourdes Montoya made an unannounced subsequent visit to the facility to deliver a complaint finding of the above allegation. Upon arrival, LPA called the facility to conduct a risk assessment. LPA spoke with Administrator Angelique Gradney, who confirmed the facility is Covid-19 free. LPA met with Staff Catherine Espino (Assistant to the Administrator). The purpose of this visit was explained.

The investigation consisted of the following: On 12/31/2019, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced 24-hour complaint visit. On 01/02/2020, LPA Montoya conducted a subsequent visit to collect copies of the records from the facility related to the complaint allegation. On 08/25/2020, this complaint was assigned to Investigator, Robert Kujawa with the California Department of Social Services, Community Care Licensing Investigation Branch. Investigator, Robert Kujawa obtained and reviewed medical records from Providence Little Company of Mary Hospital, and conducted interviews with facility and medical services staff.

REPORT CONTINUED IN LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2022
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-20191230164628
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 FE HOME CARE HOMES
FACILITY NUMBER: 198205144
VISIT DATE: 07/11/2022
NARRATIVE
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INVESTIGATIONS REVEALED:

ALLEGATION: Resident has multiple pressure injuries.

It was alleged resident has multiple pressure injuries. The investigation revealed the alleged victim, Resident #1 (R1) moved into the facility on 1/18/2012 with no injuries and no history of skin conditions or breakdown. R1 was not receiving home health services and hospice care. Medical records show on 9/27/2013, R1 began to visit a dermatologist for a left ear health condition and underwent an outpatient skin surgery on 12/14/2019. Investigator Kujawa interviewed Staff #1 (S1), who revealed that R1 refused to eat and became weak after surgery. S1 denied R1 had pressure injuries during interview. S1 stated on 12/19/2019 she called 911 and paramedics took R1 to Providence Little Company of Mary. Medical records indicate R1 was admitted to the hospital for generalized body weakness, loss of appetite, and multiple pressure injuries. On 12/20/2019, R1 was transferred to Providence Little Company of Mary Skilled Nursing Facility (SNF) and was treated for multiple pressure injuries including R lateral hip – Stage 3 – measuring: 3.1x3.1cm; Right IT – Stage 2/Unstageable – measuring: 1.9x1.5cm; L dorsal 2nd toe – Unstageable – measuring4x1cm . On 12/25/2019, medical records show R1 was placed on hospice care.

Based on the evidence gathered, interviews conducted, and records reviewed, the preponderance of evidence standard has been met: Due to neglect/lack of supervision, Resident #1 developed Stage 3 and Unstageable pressure injuries while in care, therefore the above allegation “Resident has multiple pressure injuries” is found to be SUBSTANTIATED.

California Code of Regulations (Title 22, Division 6, Chapter 8), the above-mentioned deficiencies were observed, and citations issued (ref. LIC 9099D) and civil penalty assessed.

At this time, an enhanced civil penalty determination is pending in reference to Health & Safety Code 1569.49(e)(1)(A) “Serious Bodily Injury” as defined in Section 243 of the Penal Code that states, “a serious physical condition, including, but not limited to, the following: loss of consciousness; concussion; bone fracture; protracted loss or impairment of any bodily member or organ; a wound requiring extensive suturing; and serious disfigurement.”

An exit interview was conducted and a copy of the Complaint Report and Appeal Rights were provided to House Manager, Catherine Espino.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20191230164628
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 FE HOME CARE HOMES
FACILITY NUMBER: 198205144
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/12/2022
Section Cited
CCR
87615(a)(1)
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87615 Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly: (1) Stage 3 and 4 pressure injuries. This requirement was not met as evidenced by:
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Administrator will review Title 22 Regulations, Section 87615 (a)(1) and submit a detailed written plan on how the facility will handle residents with prohibited health conditions while in care. Because the Administrator retained Resident #1 at the facility with prohibited pressure injuries (Stage 3 and Unstageable) without home health or hospice care, civil penalties are assessed in the amount of Five-hundred Dollars ($500). This plan is due to the CCLD/El Segundo ASC Office by POC date of 7/12/2022.
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Based on the evidence provided, Resident #1 was diagnosed with unstageable and Stage 3 dermal ulcers on 12/19/2019 and referred to a higher level of care (skilled nursing) due to requiring further management. This poses an immediate risk to health, safety and/or personal rights to residents in care.
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CIVIL PENALTY ASSESSED
Type A
07/12/2022
Section Cited
CCR
87466
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87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
This requirement was not met as evidenced by:
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Administrator will review Title 22 Regulations, Section 87466 and submit a detailed written plan on how the facility will document and address changes in the resident(s) condition. This plan is due to the CCLD/El Segundo ASC Office by POC date of 7/12/2022.
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Based on information gathered, interviews, and records review, Licensee failed to observe changes in resident’s condition/conduct a skin assessment of Resident #1 while residing at the facility. Resident #1 was not receiving Hospice Care or Home Health for wound care prior to hospitalization on 12/19/2019. On admission to Providence Little of Company of Mary, Resident #1 was diagnosed with multiple pressure injuries with varying stages: R lateral hip – Stage 3 – measuring: 3.1x3.1cm; Right IT – Stage 2/Unstageable – measuring: 1.9x1.5cm; L dorsal 2nd toe – Unstageable – measuring: 4x1cm. This poses an immediate risk to health, safety and/or personal rights to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20191230164628
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 FE HOME CARE HOMES
FACILITY NUMBER: 198205144
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/12/2022
Section Cited
CCR
87405(a)(d)(1)(2)
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87405 Administrator - Qualifications and Dutie (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (1) Knowledge of the requirements for providing care and supervision appropriate to the residents. (2) Knowledge of and ability to conform to the applicable laws, rules, and regulations.
This requirement was not met as evidenced by:
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Administrator will read Title 22, Section 87405(d)(1) “Administrator – Qualifications and Duties” The Administrator shall review regulations that specifically address certain issues; such as, the admittance and/or retention of a resident with a prohibited health condition and conduct an assessment of the resident. The administrator shall display knowledge of the requirements for providing care and supervision. A self-certification statement shall be shall be submitted to CCLD via email to Lourdes.montoya@dss.ca.gov
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Based on information gathered, interviews, and records review, the administrator failed to display knowledge of the requirements for providing care and supervision appropriate to the residents and knowledge of and ability to conform to the applicable laws, rules, and regulations by retaining a resident with a prohibited health condition. This poses an immediate risk to health, safety and/or personal rights to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 07/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4