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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198205144
Report Date: 01/24/2024
Date Signed: 04/15/2024 01:52:57 PM

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
01/16/2024 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20240116161744
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: 4DATE:
01/24/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ray MalitTIME COMPLETED:
03:32 PM
ALLEGATION(S):
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Facility staff does not provide resident with adequate amounts of food.


INVESTIGATION FINDINGS:
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** This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 1/24/24.

On 1/24/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by Rey Malit, Housekeeper and Angelique Gradney, Director was called. LPA explained the purpose of today’s visit and LPA was granted entry.
The investigation consisted of the following:
On 1/24/24 LPA reviewed resident files and toured the facility. LPA reviewed copies of the following records: Staff Roster, resident files, resident MAR, Admission Agreement, ID and Emergency information, resident appraisal, Preplacement Appraisal, Appraisal Needs and Services, medical record of outpatient medications, copy of weekly menu’s.

The investigation revealed the following:
Con'd on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
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 5
Control Number 11-AS-20240116161744
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: 01/24/2024
NARRATIVE
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Allegation: Facility staff does not provide resident with adequate amounts of food


Resident is concerned that meal portion amounts are too small. Resident also states that the food is good in quality just not enough food. Resident states that’re working out and wants to be fit, but occasionally wants more food. Resident states that he is given extra food sometimes, but not all of the time. LPA observed vegetables being prepped for daily soup which is on the menu for the day. LPA observed that some of the residents had soul food containers brought in from family. During interviews LPA learned that a majority of the meals are Filipino based meals. LPA discussed with the Administrator to consider revising the weekly menu to represent all residents in care.
On 1/24/24 LPA Shirley conducted interviews with both staff and residents. LPA interviewed staff, staff 1 – staff 2 (S-1 – S-2). LPA asked staff, “Does staff provide residents with adequate amounts of food?” Of those interviewed 2 out of 2 answered yes. LPA interviewed residents 1 – resident 4 (R-1 – R-4). LPA asked residents, Do you feel like you are getting adequate amounts of food? Of those interviewed, 3 out of 4 answered, yes.

Based on information gathered, the department did not find sufficient evidence to support allegations "Facility staff does not provide resident with adequate amounts of food,” therefore the allegation is Unsubstantiated.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
01/16/2024 and conducted by Evaluator Felisa Shirley
COMPLAINT CONTROL NUMBER: 11-AS-20240116161744

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: 4DATE:
01/24/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Ray MalitTIME COMPLETED:
03:32 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff mismanages resident's medications
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
** This report serves as an amendment to clarify findings. It does not supersede the complaint investigation findings reflected on report created 1/24/24.

On 1/24/24, Licensing Program Analyst (LPA) Felisa Shirley conducted an unannounced visit to this facility. LPA was met by Rey Malit, Housekeeper and Angelique Gradney, Director was called. LPA explained the purpose of today’s visit and LPA was granted entry.

The investigation consisted of the following:

On 1/24/24 LPA reviewed resident files and toured the facility. LPA reviewed copies of the following records: Staff Roster, resident files, resident MAR, Admission Agreement, ID and Emergency information, resident appraisal, Preplacement Appraisal, Appraisal Needs and Services, medical record of outpatient medications, copy of weekly menu’s.
The investigation revealed the following:
Con'd on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 11-AS-20240116161744
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: 01/24/2024
NARRATIVE
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Allegation: Facility staff mismanages resident’s medication

It is being alleged that staff is mismanaging medication. LPA Shirley conducted a review of resident’s service file including Medication Administration Records (MAR). Records revealed that there are two medications listed on MAR with initials for administering medication. Upon review of medications, LPA was not able to locate either medication in the medication basket. LPA observed another prescribed medication in the basket but medication is not listed on MAR. According to the information gathered and the acknowledgment declaration from staff, there is sufficient evidence to support the allegation mentioned above. Based on interviews, observation, and record reviews the licensee violated the California Code Regulations (CCR) of Title 22, Division 6, Chapter 8, therefore this allegation is Substantiated.

Deficiencies are issued and an exit interview is conducted Nelson Ortega, Administrator's designee. A copy of this report and appeal rights were provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 11-AS-20240116161744
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
02/07/2024
Section Cited
CCR
87465(e)
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Incidental Medical and Dental Care (e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.
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Licensee will submit plan informing the department medication training has been peformed with all staff. A written proof of correction must included date, time and particpants names. Correction must be submitted by due date: 02/07/24 to LPA's email: felisa.shirley@dss.ca.gov
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This requirement was not met as evidenced by:
Based on interviews and records reviews, the facility staff failed to make accurate records for prescribed medications for residents. Staff failed to refill prescriptions on file. Staff failed to list all medications on the MAR. This violation poses a potential health, safety, or personal rights risk to persons 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: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Felisa Shirley
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5