Community Care Licensing

Document Has Been Signed on 12/27/2023 05:59 PM - It Cannot Be Edited

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:	12/27/2023
TYPE OF VISIT:	Case Management - Annual Continuation	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Ray Malit - House Manager/Caregiver		TIME COMPLETED:	06:00 PM

SUPERVISORS NAME: Ulysses Coronel LICENSING EVALUATOR NAME: Socorro Leandro LICENSING EVALUATOR SIGNATURE: DATE: 12/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/26/2023

Link to Parent Document Below:

FACILITY NAME: SANTA FE HOME CARE HOMES	FACILITY NUMBER: 198205144
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/27/2023

Type A

Section Cited

CCR

87309(a)

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in unlocked counterops containing cleaning solutions, poisons, medications, and knives, there were also cleaning solutions and poisons out on countertops, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/28/2023
	Plan of Correction
1 2 3 4	Licensee will lock disinfectants, cleaning solutions, poisons, and knives. Licensee will also retrain all staff on how to properly store dangerous items that can pose an immediate health or safety risk to persons in care. Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Ulysses Coronel LICENSING EVALUATOR NAME: Socorro Leandro LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2023

Document is an Amendment of Original Document on 01/24/2024 05:05 PM

Link to Parent Document Below:

FACILITY NAME: SANTA FE HOME CARE HOMES	FACILITY NUMBER: 198205144
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/27/2023

Type B

Section Cited

CCR

87411(f)

(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out 4 staff records did not have health screening reports and 3 out of 4 staff records did not have a current tuberculosis test, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/30/2024
	Plan of Correction
1 2 3 4	Licensee will email health screening reports for Staff 1 & Staff 4. Licensee will email tuberculosis test for Staff 1, Staff 3, & Staff 4. Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.

SUPERVISOR'S NAME: Ulysses Coronel LICENSING EVALUATOR NAME: Socorro Leandro LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2023

Document is an Amendment of Original Document on 01/24/2024 05:07 PM

Link to Parent Document Below:

FACILITY NAME: SANTA FE HOME CARE HOMES	FACILITY NUMBER: 198205144
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/27/2023

Type B

Section Cited

CCR

87202(a)(2)

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in having a residnet who is bedridden (facility does not have a fire clearence for a bedridden resident), which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/30/2024
	Plan of Correction
1 2 3 4	1) Licensee will request a fire clearnce for a bedridden resident. 2) Licensee will submit appropiate documentation to CCLD and request to approve a bedridden resident in their facility. 3) Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.

Type B

Section Cited

HSC

1569.605

On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in having an expired liability insurance, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/16/2024
	Plan of Correction
1 2 3 4	Licensee will update their liability insurance and email to Socorro.Leandro@dss.ca.gov.

SUPERVISOR'S NAME: Ulysses Coronel LICENSING EVALUATOR NAME: Socorro Leandro LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2023

Document is an Amendment of Original Document on 01/24/2024 05:10 PM

Link to Parent Document Below:

FACILITY NAME: SANTA FE HOME CARE HOMES	FACILITY NUMBER: 198205144
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/27/2023

Type B

Section Cited

CCR

87303(a)

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in green slippery mold across the facility entrance walkway, dry stains of feces on toilets in bathrooms 2 & 3, and the garage was filled with old furniture, scattered clothing, a wheelchair, boxes, etc., which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/30/2024
	Plan of Correction
1 2 3 4	Facility will remove the green mold on their concreate walkways, thoroughly clean bathrooms 2 & 3, and remove and organize items in their garage. Licensee will also create a cleaning schedule for their facility. Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.

Type B

Section Cited

CCR

87303(e)(6)

(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having a leaky shower head and the shower valve was in disrepair (difficult to turn off water) in bathroom 2, bathroom 3's toilet is loose and leaking, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/30/2024
	Plan of Correction
1 2 3 4	Licensee will fix shower in bathroom 2 and will fix toilet in bathroom 3. Licensee will emailed proof of correction to Socorro.Leandro@dss.ca.gov.

SUPERVISOR'S NAME: Ulysses Coronel LICENSING EVALUATOR NAME: Socorro Leandro LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2023

Document is an Amendment of Original Document on 01/24/2024 05:11 PM

Link to Parent Document Below:

FACILITY NAME: SANTA FE HOME CARE HOMES	FACILITY NUMBER: 198205144
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/27/2023

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Type B

Section Cited

CCR

87305(a)

Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in creating a new bedroom (the bedroom for the non-resident) and creating a wall that divides the caretakes room in two without providing CCLD with a building permit prior to construction, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/30/2024
	Plan of Correction
1 2 3 4	1) Licensee will have their local authority (city) inspect thier new construction and receive approval for their new construction. 2) Licensee will email approval of their new construction and an updated facility sketch (LIC 999) to Socorro.Leandro@dss.ca.gov.

SUPERVISOR'S NAME: Ulysses Coronel LICENSING EVALUATOR NAME: Socorro Leandro LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2023

Document is an Amendment of Original Document on 01/24/2024 05:12 PM

Link to Parent Document Below:

FACILITY NAME: SANTA FE HOME CARE HOMES	FACILITY NUMBER: 198205144
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/27/2023

Type B

Section Cited

CCR

87307(a)(3)(D)

(D) Hygiene items of general use such as soap and toilet paper. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in not having hand soap in bathroom 2 and in the handwashing station in the dinning room, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/16/2024
	Plan of Correction
1 2 3 4	Lincensee will place hand soap in the bathroom 2 and in the handwashing station in the dinning room. Licensee will retrain staff to place hygiene products where necessary. Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.

Type B

Section Cited

CCR

87412(a)

(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in not having Staff 4's file, having missing documents for Staff 1, Staff 2, and Staff 4, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/30/2024
	Plan of Correction
1 2 3 4	Licensee will create a file for Staff 4; update Staff 1's file to include CPR/First Aid certificate, LIC501, LIC503, Tuberculosis Test, Training documents missing Administrator signature & dates; update Staff 2's training documentsto include dates; and update Staff 3's file to include Tuberculosis Test (read 6/11/2014), and CPR/First Aid Certificate (Exp. 8/30/2021). Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.

SUPERVISOR'S NAME: Ulysses Coronel LICENSING EVALUATOR NAME: Socorro Leandro LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2023

Link to Parent Document Below:

FACILITY NAME: SANTA FE HOME CARE HOMES	FACILITY NUMBER: 198205144
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/27/2023

Type B

Section Cited

CCR

87468(d)

(d) Licensees shall post the personal rights, nondiscrimination notice, and complaint information specified above in English, and, in any other language in which at least five (5) percent of the residents can only read that other language. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above in not posting a nondiscrimination notice, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/16/2024
	Plan of Correction
1 2 3 4	Licensee will post a nondiscrimination notice and email proof of correction to Socorro.Leandro@dss.ca.gov.

Type B

Section Cited

HSC

1569.319(a)

(a) A licensee of a facility that has internet service shall provide at least one internet access device, such as a computer, smart phone, tablet, or other device, that can support real-time interactive applications, is equipped with videoconferencing technology, including microphone and camera functions, and is dedicated for resident use. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and intervie, the licensee did not comply with the section cited above in not providing a videoconferencing device dedicated for client use, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/16/2024
	Plan of Correction
1 2 3 4	Licensee will place a videoconferencing device dedicated for client use in their facility and email proof of correction to Socorro.Leandro@dss.ca.gov.

SUPERVISOR'S NAME: Ulysses Coronel LICENSING EVALUATOR NAME: Socorro Leandro LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2023

Link to Parent Document Below:

FACILITY NAME: SANTA FE HOME CARE HOMES	FACILITY NUMBER: 198205144
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/27/2023

Type B

Section Cited

CCR

87219(a)(1)

(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include: (1) Socialization, achieved through activities such as group discussion and conversation, recreation, arts, crafts, music, and care of pets. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews with residents, the licensee did not comply with the section cited above in not providing residents with planned activities, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/16/2024
	Plan of Correction
1 2 3 4	Licensee create a schedule and implement of activites and email proof of correction to Socorro.Leandro@dss.ca.gov.

Type B

Section Cited

CCR

87219(i)

(i) Facilities shall provide sufficient equipment and supplies to meet the requirements of the activity program including access to daily newspapers, current magazines and a variety of reading materials. Special equipment and supplies necessary to accommodate physically handicapped persons or other persons with special needs shall be provided as appropriate. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in having suffient equipment and supplies to meet the requirements of the activities, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/16/2023
	Plan of Correction
1 2 3 4	Licensee will provide sufficient equipment and supplies to meet the requirements of activities including access to daily newspapers, current magazines and a variety of reading materials and email proof of correction to Socorro.Leandro@dss.ca.gov.

SUPERVISOR'S NAME: Ulysses Coronel LICENSING EVALUATOR NAME: Socorro Leandro LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2023

Document is an Amendment of Original Document on 01/24/2024 05:13 PM

Link to Parent Document Below:

FACILITY NAME: SANTA FE HOME CARE HOMES	FACILITY NUMBER: 198205144
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/27/2023

Type B

Section Cited

CCR

87555(b)(27)

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in having roaches and mice in the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/30/2024
	Plan of Correction
1 2 3 4	Licensee will hire an exterminator and email proof of correction to Socorro.Leandro@dss.ca.gov.

Type B

Section Cited

CCR

87465(h)(5)

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above in using medicine pill planner per each resident, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/16/2024
	Plan of Correction
1 2 3 4	Licensee will store medications in its orginal container. Licensee will retrain staff on how to store and provide medications to their residents. Licensee will email proof of correction to Socorro.Leandro@dss.ca.gov.

SUPERVISOR'S NAME: Ulysses Coronel LICENSING EVALUATOR NAME: Socorro Leandro LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2023

Link to Parent Document Below:

FACILITY NAME: SANTA FE HOME CARE HOMES	FACILITY NUMBER: 198205144
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/27/2023

Type B

Section Cited

HSC

1569.695(a)

(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in not having the updated Emergency and Disaster Plan (LIC 610E 3/19 Form) available in the facility, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/16/2024
	Plan of Correction
1 2 3 4	Licensee will email their updated Emergency and Disaster Plan to Socorro.Leandro@dss.ca.gov.

Section Cited

	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

SUPERVISOR'S NAME: Ulysses Coronel LICENSING EVALUATOR NAME: Socorro Leandro LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2023

FACILITY NAME: SANTA FE HOME CARE HOMES	FACILITY NUMBER: 198205144
	VISIT DATE: 12/27/2023