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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198205144
Report Date: 09/26/2024
Date Signed: 09/26/2024 03:24:14 PM

Document Has Been Signed on 09/26/2024 03:24 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:SANTA FE HOME CARE HOMESFACILITY NUMBER:
198205144
ADMINISTRATOR/
DIRECTOR:		ANGELIQUE GRADNEYFACILITY TYPE:
740
ADDRESS:2340 SANTA FE AVENUETELEPHONE:
(424) 488-2079
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 2DATE:
09/26/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:46 PM
MET WITH:Christina EspinoTIME VISIT/
INSPECTION COMPLETED:
02:47 PM
NARRATIVE
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On 09/26/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a Case Management visit at this facility. LPA met with caregiver Christian Espino who allowed for entry in this facility. LPA informed Espino the purpose of the visit is to conduct a health and safety check in association with the annual inspection visit conducted on 08/02/24.

In the annual inspection conducted on 08/02/24, Licensing Program Analyst (LPA) Regina Cloyd observed (2) out of the (4) residents did not occupy the proper rooms for non-ambulatory or/ambulatory. Resident #1 who is non-ambulatory was in an ambulatory room. Resident #3 is ambulatory and was in a non-ambulatory room. The facility was not compliant and was issued a citation under Title 22 Regulation 87204(b).

LPA Dabuet conducted a health and safety check and observed Resident #1 now resides in a non-ambulatory room #2. Resident #3 is no longer a resident at the facility. During the inspection, LPA Dabuet reviewed Resident #1 and Resident #2 Physician's Report LIC 602A (dated: 02/22/22 and 02/16/23). Resident #1 (R1) is non-ambulatory requires continuous bed care, is bladder/bowel impairment, and requires assistance with toileting needs. According to the LIC 500 Personnel Report (dated: 02/01/24) and staff #1's interview, no staff worked after 8:00 pm until 7:00 am. It was revealed that there are no night-shift workers at the facility to provide the services necessary to meet resident needs.

Based on observations, interviews, and record reviews, a preponderance of evidence standard has been met. The facility did not have night shift worker to provide services necessary to meet resident needs. Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 809-D.

An exit interview was conducted with Christian Espino, and a hard copy of the report along with appeal rights.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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 09/26/2024 03:24 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 09/26/2024 at 01:47 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
, 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: 09/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2024
Section Cited
CCR
87411(a)

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87411 - Personnel Requirements - General (a) Facility personnel shall...be sufficient in numbers...to provide the services necessary to meet resident needs. Additional staff shall be employed as necessary..The licensing agency may require...staff..needs of the particular residents, the extent of services provided...adequate services.
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Licensee/Administrator have agreed to hire an overnight staff in order to attend to residents' needs while in care. Administrator will send an updated LIC500 to LPA Dabuet, via email, at Ernand.Dabuet@dss.ca.gov
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This has not been met as evidenced by:
Based on record review/interview (R1) requires continious bed care who is bladder/bowel incontinent. Facility did not have a night staff to meet (R1)'s needs after 7pm. This violation which poses a potential health and safety to residents 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.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2024


LIC809 (FAS) - (06/04)
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