198205144-8-2-2024-11-AS-RCLD-D7RV84-20240802161206

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198205144
Report Date: 08/02/2024
Date Signed: 08/02/2024 04:12:17 PM

Document Has Been Signed on 08/02/2024 04:12 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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	SANTA FE HOME CARE HOMES		FACILITY NUMBER:	198205144
ADMINISTRATOR/ DIRECTOR:	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:	08/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:24 AM
MET WITH:	Administrator Catherine Espino		TIME VISIT/ INSPECTION COMPLETED:	04:30 PM

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On 08/02/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Staff Christian Espino. Backup Administrator Catherine Espino joined us later.

This facility is licensed to serve 6 adults ages 60 and above, of which 2 may be non-ambulatory residents. Rooms 1 & 4 are for ambulatory residents. Rooms 2 & 3 are for non-ambulatory residents. A total of 4 residents are currently residing in this facility, of which 2 are ambulatory and 2 is non-ambulatory.

The facility is a one-story house located on a residential street. The home consists of 4 resident bedrooms, 2 staff bedrooms, 1 ensuite bedroom (bedroom is connected to its own bathroom), 1 bathroom, 1 toilet room, 1 living room, 1 kitchen/dining/tv room, 1 attached garage, and front and backyard patio areas have shaded seating.

Staff accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards.

Resident bedrooms had the required furniture and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Continue to LIC809-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

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 08/02/2024 04:12 PM - It Cannot Be Edited

Created By: Regina Cloyd On 08/02/2024 at 03:15 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 08/02/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87204(b)

Limitations -Capacity and Ambulatory Status

(b) Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents. Residents whose condition becomes nonambulatory shall not remain in rooms restricted to ambulatory residents. 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 for two out of four residents which poses a potential safety risk to persons in care. LPA Cloyd observed nonambulatory Resident #2 in an ambulatory room #1. LPA Cloyd observed an ambulatory Resident #3 in a nonambulatory room #2r
	POC Due Date: 08/20/2024
	Plan of Correction
1 2 3 4	The Licensee will move Resident #2 into an approved nonambulatory room within the facility prior to the POC due date. The Licensee will compare the ambulatory status of residents to the facility's map prior to new move-in. This is to help ensure that nonambulatory residents are in rooms 2 & 3 and ambulatory residents are in rooms 1 & 4.

Type B

Section Cited

CCR

87555(b)(27)

General Food Service Requirements

(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 the kitchen and dining room area which poses a potential health risk to persons in care. LPA Cloyd observed vermin in the kitchen cabinet near the cereal and on the baseboard near the dining table.
	POC Due Date: 08/20/2024
	Plan of Correction
1 2 3 4	The Licensee will increase its pest control services from quarterly to monthly from August 2024 - August 2025. The first service in August should occur before the POC due date. The Licensee will email proof of correction and an updated service contract to regina.cloyd@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:

Ulysses Coronel

LICENSING EVALUATOR NAME:

Regina Cloyd

LICENSING EVALUATOR SIGNATURE:

DATE: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SANTA FE HOME CARE HOMES	FACILITY NUMBER: 198205144
	VISIT DATE: 08/02/2024

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Resident bathrooms were checked. Grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, and hot water temperature properly measured at 105.2 degree F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

Common areas were clean and clear of hazards, doorways were free of obstructions.

LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in locked storage cabinet. First Aid kit was available. One fire extinguisher, last serviced August 11, 2023 was observed in the kitchen area. Staff tested the carbon monoxide detector and smoke detectors in the house. Both devices were functional.

5 staff records were reviewed, 5 out of 5 staff records had required criminal record clearances or criminal record exemptions.

4 resident records were reviewed and, 4 out of 4 residents' records had medical assessments and pre-appraisal or reappraisals. Two residents’ medication was reviewed.

Deficiencies are being cited based on LPA observations in accordance with the California Code of Regulations, Title 22, see LIC809D.

LPA Cloyd observed vermin in the kitchen cabinet near the cereal and on the baseboard in the dining room.

Continue to LIC809-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SANTA FE HOME CARE HOMES	FACILITY NUMBER: 198205144
	VISIT DATE: 08/02/2024

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 26 27 28 29 30 31 32	LPA Cloyd observed a nonambulatory resident #2 in an ambulatory room #1. An exit interview was conducted, plans of correction developed, and a copy of this report and appeals was discussed and left with Backup Administrator Catherine D Espino.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

LIC809 (FAS) - (06/04)

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