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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198205144
Report Date: 07/11/2022
Date Signed: 07/13/2022 12:44:23 PM


Document Has Been Signed on 07/13/2022 12:44 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 FE HOME CARE HOMESFACILITY NUMBER:
198205144
ADMINISTRATOR:ANGELIQUE GRADNEYFACILITY TYPE:
740
ADDRESS:2340 SANTA FE AVENUETELEPHONE:
(424) 488-2079
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY:6CENSUS: 3DATE:
07/11/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:CATHERINE ESPINO TIME COMPLETED:
06:00 PM
NARRATIVE
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On 7/11/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted a case management - annual continuation visit at the above facility. Upon arrival at the facility, LPA Montoya called the facility, spoke with Administrator Angelique Gradney and conducted a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection. Upon arrival, LPA met with Staff Catherine Espino (Assistant to the Administrator) who assisted with the visit.

LPA Montoya and Staff Espino toured the inside and outside grounds of the facility. Staff Espino presented to LPA a resident file (service records) of the occupant of bedroom #5. As mentioned in previous report dated 7/8/2022, the occupant of bedroom #5 is not an employee and not a resident per Staff Espino and Staff #1. In addition, the register of residents/clients presented to LPA on 7/8/222 does not show the name of the occupant of bedroom #5. LPA obtained copies of the aforementioned records for review.

LPA checked the resident bedrooms and observed bedroom #1 which is designated for ambulatory resident is being occupied by Resident #1 who is non-ambulatory.

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

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

SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
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
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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Document Has Been Signed on 07/13/2022 12:44 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 FE HOME CARE HOMES
FACILITY NUMBER: 198205144

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPA observed a broken sliding door screen by the kitchen; a hanging light disconnected from its plate on the ceiling by the dining area; bedroom #5 is dirty and cluttered; the garage is cluttered and filled with old furniture, scattered clothing, wheelchair, boxes, etc. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2022
Plan of Correction
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Administrator shall ensure the above deficiencies are cleared by the POC due date. Proof of corrections shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
Type B
Section Cited
CCR
87208(a)
Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. LPA observed resident bedroom #5 is being occupied by a nonresident. Staff Espino and Staff #1 confirmed that the person living in bedroom #5 is not a resident and not a staff but a family member of the licensee. This poses potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2022
Plan of Correction
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Administrator shall submit an updated plan of operation to reflect the changes mentioned above. Proof of correction shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.

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: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
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
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/13/2022 12:44 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 FE HOME CARE HOMES
FACILITY NUMBER: 198205144

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)(1)
(g) All personnel records shall be maintained at the facility and shall be available to the licensig agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. LPA did not observe personnel records for Staff #1 and Staff #2. Staff Espino confiirmed Staff #1 and Staff #2 don't have personnel records on file in the facility or outside the facility. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/21/2022
Plan of Correction
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Administrator shall ensure all pesonnel records shal lbe maintained in the facility and shall be available to the licensing for review. Administrator shall produce and maintain personnel records for Staff #1 and Staff #2. Proof of correction shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4

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: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
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
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/13/2022 12:44 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 FE HOME CARE HOMES
FACILITY NUMBER: 198205144

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(b)

(b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residentt whose condition becomes nonambultory shall not remain in rooms restricted to ambulatory residents.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. LPA observed Resident #1 who is non ambulatory is occupying bedroom #1 which is designated for ambulatory residents only. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2022
Plan of Correction
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Administrator shall transfer Resident #1 to either bedroom # 2 or #3 which are designated rooms for nonambulatory residents. Proof of corrections shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
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
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/13/2022 12:44 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 FE HOME CARE HOMES
FACILITY NUMBER: 198205144

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(1)(2)
(e) 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: (1) Obtain a California clearance or a criminal record exemption as required by the Department or (2) Request a transfer of a criminal record clearance as especified 87355(c)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. LPA did not observe a criminal record clearance for Staff #1 who was on duty during the visit on 7/8/2022. Caregivers (Staff #1 and Staff #2) who were present during the visit on 7/8/2022 are not associated to the facility according to LPA's review of the Facility Personnel Report Summary (LIS) printed on 7/6/2022. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2022
Plan of Correction
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Administrator shall ensure all staff have criminal record clearances prior to working. Staff #1 and Staff #2 stopped working and LPA did not see them on today's visit. Proof of correction shall be submitted to CCL via email to lourdes.montoya@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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3
4

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: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
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
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/13/2022 12:44 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 FE HOME CARE HOMES
FACILITY NUMBER: 198205144

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87405(d)(2)
(d) The administrator shall have the qualifications specified in Section 87405(d)(1) through (7) if the licensee is also the administrator all requirements for an administrator shall apply (2) knowledge of and ability to conform to the applicable laws, rules and regulations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview ad record review, the licensee did not comply with the section cited above. The administrator allowed Staff #1 to commence working in the facility with direct contact with residents without a criminal record clearance. Staff #1 and Staff #2 were not associated to the facility prior to working. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2022
Plan of Correction
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Administrator shall ensure all staff have criminal clearance prior to working. Administrator shall review the section cited herein and self-certify to adhere to the regulations. Proof of correction shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4

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: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
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
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/13/2022 12:44 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 FE HOME CARE HOMES
FACILITY NUMBER: 198205144

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87203

All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshall for the protection of life and property against fire and panic.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPA did not observe smoke detectors in bedroom #5 and bedroom #3 (Staff room/Isolation room). This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/12/2022
Plan of Correction
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Administrator shall install smoke detectors in bedroom #5 and #3. Proof of correction shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
Section Cited
Deficient Practice Statement
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2
3
4
POC Due Date:
Plan of Correction
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2
3
4

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: Eva M AlvarezTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
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
LIC809 (FAS) - (06/04)
Page: 7 of 7