198205144-3-7-2025-11-AS-JHAD-DERVCK-20250314161915

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198205144
Report Date: 03/07/2025
Date Signed: 03/07/2025 10:24:08 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/09/2024 and conducted by Evaluator Perry Scott

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20240209103510

FACILITY NAME:	SANTA FE HOME CARE HOMES		FACILITY NUMBER:	198205144
ADMINISTRATOR:	ANGELIQUE GRADNEY		FACILITY TYPE:	740
ADDRESS:	2340 SANTA FE AVENUE		TELEPHONE:	(424) 488-2079
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY:	6	CENSUS: 4	DATE:	03/07/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Christian Espino		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

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Resident sustained bed sores due to staff neglect.
Staff hit resident.
Staff are not safeguarding resident's personal belongings.
Staff are not providing adequate food service to residents.
Staff did not provide resident with a 60day rent increase notice.
Staff are threatening resident.
Staff did not ensure resident's wheelchair was in good repair.

INVESTIGATION FINDINGS:

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**This report supersedes the previous report dated 2/16/24 to correct the order of pages for the complaint report. **

On 3/7/25, at 9:30am, Licensing Program Analyst (LPA) Perry Scott conducted an unannounced subsequent complaint visit to amend the complaint to correct the order of the pages. LPA was met by Christian Espino, Caregiver, and the purpose of the visit was explained.

On 02/16/2024 at 08:08 am Licensing Program Analyst (LPA) David España conducted an unannounced complaint investigation visit for the allegation listed above. LPA met with Administrator, Catherine Espino and the purpose of today’s visit was discussed. Upon arrival at the facility, LPA conducted a risk assessment at the front door. Based on the assessment, the facility is clear of Covid-19 infection. LPA was granted access.

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20240209103510

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SANTA FE HOME CARE HOMES	FACILITY NUMBER: 198205144
	VISIT DATE: 03/07/2025

NARRATIVE

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The investigation consisted of the following: An initial complaint visit was completed by LPA David España on 02/16/2024. A subsequent visit was completed by LPA Perry Scott on 3/7/2025. On 02/16/2024 LPA requested copies of the following: Resident's medical records, including diagnosis and treatment of pressure sores. Documentation of care provided by appropriately skilled professionals. Records of staff training on pressure sore prevention and care. Resident's care plan and daily care logs. Incident reports. Staff disciplinary records. Resident's medical records documenting any injuries. Facility policies on abuse prevention and reporting. Resident's personal property inventory. Facility policies on safeguarding residents' belongings. Staff training records on resident rights and property protection. Any reports of missing items.

Meal plans and menus. Food service logs. Dietary requirements for residents. Staff training records on food service and nutrition. Copies of rent increase notices. Facility policies on rent increases and notifications. Resident's admission agreement. Communication logs with residents or their representatives. Facility policies on resident rights and staff conduct. Maintenance logs for resident mobility devices. Inspection records for wheelchairs and other mobility devices. Resident's care plan addressing mobility needs. Staff training records on equipment maintenance and safety. LPA España interviewed Resident 1- Resident 3 (R1-R3) and Staff 1 - Staff 4 (S1-S4).

Investigation revealed the following: Allegation #1: Resident sustained bed sores due to staff neglect.

On 02/16/2024, LPA España interviewed Resident 1 - Resident 3 (R1-R3) regarding the allegation. Of those interviewed, 1 of 3 residents stated they had no bed sores, the other two did not answer the question. On 02/16/2024, LPA España interviewed Staff 1-Staff 4 (S1-S4). 3 out of 4 staff disagreed with the allegation of neglect leading to bed sores. On 2/16/2024 LPA Espana reviewed records for four facility residents and found no indication of any residents being treated for bedsores.

Page 2 of 6 Continued On LIC9099-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 11-AS-20240209103510

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SANTA FE HOME CARE HOMES	FACILITY NUMBER: 198205144
	VISIT DATE: 03/07/2025

NARRATIVE

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Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated.

Allegation #2: Staff hit resident.

On 02/16/2024 LPA España interviewed Resident 1 - Resident 3 (R1-R3). Of those interviewed, 3 out of 3 residents denied the allegation. On 02/16/2024 LPA España interviewed Staff 1- Staff 4 (S1-S4). 3 out of 4 staff members denied the allegation. On 02/16/2024 LPA España reviewed facility records and found no Unusual Incident/ Injury regarding staff hitting residents.

Allegation #3: Staff are not safeguarding resident's personal belongings.

On 02/16/2024 LPA España interviewed Resident 1 - Resident 3 (R1-R3). Of those interviewed, 2 out of 3 denied the allegation. On 02/16/2024 LPA España interviewed Staff 1- Staff 4 (S1-S4). Of those interviewed, 2 out of 4 denied the allegation and the other two indicated they had insufficient knowledge to answer, as they were newer employees to the facility.

Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated.

Page 3 of 6 Continued On LIC9099-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 11-AS-20240209103510

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SANTA FE HOME CARE HOMES	FACILITY NUMBER: 198205144
	VISIT DATE: 03/07/2025

NARRATIVE

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Allegation #4: Staff are not providing adequate food service to residents.

On 02/16/2024 LPA España noted that the facility had a weeks’ worth of non-perishables and two days’ worth of perishable food items. A review of the weekly menu shows residents receive three meals and snacks daily. On 02/16/2024 LPA España observed residents eating a breakfast of toast, jam, and eggs, which aligned with the posted weekly menu. On 02/16/2024 LPA España interviewed Resident 1 - Resident 3 (R1-R3). Of those interviewed 2 out of 3 denied the allegation. On 02/16/2024 LPA España interviewed Staff 1- Staff 4 (S1-S4). Of those interviewed, 4 out of 4 denied the allegation.

Allegation #5: Staff did not provide resident with a 60-day rent increase notice.

On 02/16/2024 LPA España reviewed facility records and observed a rate increase notice dated 60 days before the effective date. Interview with Administrator Catherine Espino revealed that facility is supposed to provide increase notices to residents in writing. Administrator also added that it is part of the admissions contact which is signed by residents and families. On 02/16/2024 LPA España interviewed Residents 1-3 residents (R1-R3). Of those interviewed, 2 out of 3 were aware of a rent increase, but only one spoke about when it was received, stating they had only recently been told, but that family would know more. On 02/16/2024 LPA España interviewed Staff 1- Staff 4 (S1-S4). Of those interviewed, one denied the allegation and the other three were unaware of rent increases.

Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated.

Page 4 of 6 Continued On LIC9099-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 11-AS-20240209103510

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SANTA FE HOME CARE HOMES	FACILITY NUMBER: 198205144
	VISIT DATE: 03/07/2025

NARRATIVE

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Allegation #6: Staff are threatening resident.

On 02/16/2024 LPA España interviewed Staff 1- Staff 4 (S1-S4). Of those interviewed, 4 out of 4 denied the allegation, with one adding that such behavior is not tolerated and is a personal rights violation. On 02/16/2024 LPA España interviewed Residents 1-3 residents (R1-R3). Of those interviewed, 2 out of 3 denied the allegation while one did not answer the question. LPA España facility records and found no incidents reports for the 30-day period reviewed related to any threats.

Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is Unsubstantiated.

Allegation #7: Staff did not ensure resident's wheelchair was in good repair.

On 02/16/2024, LPA España reviewed facility records which show that three resident use wheelchairs for mobility. On 02/16/2024 LPA España interviewed Staff 1- Staff 4 (S1-S4). Of those interviewed, 4 out of 4 reported no issue with resident’s wheelchairs. Interview with Administrator Catherine Espino revealed that most of the time medical equipment is provided by home health and any issues are reported to them. Further, S1-S4 stated that residents have no problems using or accessing their wheelchair in the facility.

LPA interviewed the Administrator who stated that the facility’s best practices for wheelchair maintenance are as follows and staff ensures the wheelchairs are in good repair: The facility implements a regular cleaning schedule, wiping down the wheelchair with a damp cloth weekly to remove dirt and debris.

Page 5 of 6 Continued On LIC9099-C

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 11-AS-20240209103510

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SANTA FE HOME CARE HOMES	FACILITY NUMBER: 198205144
	VISIT DATE: 03/07/2025

NARRATIVE

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Perform weekly brake checks to ensure they are operating properly and engaging/releasing correctly. Inspect tire pressure regularly and adjust as needed, rechecking brake function after any pressure changes. Train staff on basic wheelchair inspection and maintenance procedures to identify problems early. Keep a maintenance log to track regular upkeep and any repairs needed.

On 02/16/2024 LPA España interviewed residents 1-3 residents (R1-R3). 2 out of 3 residents stated staff were good at moving bedridden and wheelchair-using residents. 2 out of 3 residents see other residents being moved throughout the day but couldn't specify how often. 2 out of 3 residents stated that other residents who can't walk are moved regularly with staff help. 2 out of 3 residents stated that staff move these residents, and they are seen in different locations during the day. 2 out of 3 residents stated residents who can't walk are moved regularly with staff help. 2 out of 3 residents stated staff move residents, and they are seen in different locations during the day. LPA reviewed documentation of resident council meetings or other forums where residents may have voiced concerns. Based on information gathered, the Department did not find sufficient evidence to support the allegation mentioned above.

Based on interviews, observations, and records reviewed, there is insufficient evidence to support the allegations that 1. "Resident sustained bed sores due to staff neglect," 2. "Staff hit resident. 3."Staff are not safeguarding resident's personal belongings," 4."Staff are not providing adequate food service to residents," 5. "Staff did not provide resident with a 60-day rent increase notice," 6. "Staff are threatening resident," and 7. "Staff did not ensure resident's wheelchair was in good repair."

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore all allegations are Unsubstantiated.

There were no deficiencies issued.

An exit interview was conducted, and a copy of this report provided to Christian Espino, Caregiver.

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SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Perry Scott
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2025

LIC9099 (FAS) - (06/04)

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