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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198205144
Report Date: 03/06/2024
Date Signed: 03/06/2024 03:10:26 PM

Substantiated


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
02/27/2024 and conducted by Evaluator Jose Calderon
COMPLAINT CONTROL NUMBER: 11-AS-20240227140101
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:
03/06/2024
UNANNOUNCEDTIME BEGAN:
09:17 AM
MET WITH:STAFF CARMELITA BONIFACIOTIME COMPLETED:
03:15 PM
ALLEGATION(S):
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Facility staff did not assist resident with arranging transportation to medical appointments.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jose Calderon conducted an unannounced visit to Santa Fe Home Care Homes facility on 03/06/2024 and was greeted by Administrator Nelson Ortega (A1). LPA Calderon spoke to A1 prior to entering the facility to conduct a risk assessment. LPA Calderon explained the purpose of this visit is to deliver the findings pertaining to the above-mentioned allegation and conducted an in-person interview with Administrator Nelson Ortega (A1).

The investigation consisted of the following: LPA Calderon interviewed Administrator (A1), Staff (S1-S3), resident (R1-R4) and witness (W1-W3). These interviews were conducted on 03/06/2024. LPA Calderon obtain and reviewed the following: Physician’s report (dated 09/20/2023) Vehicle transportation logs (date 01/17/2024, 02/07/2024 and 02/08/2024, doctors’ appointment (date 02/07/2024 to 05/15/2024), admission agreement (date 09/20/2024) for R1.

The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024
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 3
Control Number 11-AS-20240227140101
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: 03/06/2024
NARRATIVE
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Regarding Allegation #1: Facility staff did not assist residents with arranging transportation to medical appointment.

This complaint alleged staff did not arrange transportation for R1 doctor’s appointment. LPA Calderon interviewed with A1. A1 states that staff does help R1 make doctors’ appointments with the VA hospital. A1 states that R1 did not have an appointment with the VA and no transportation was made. A1 states that staff do keep records of residents’ transportation requests. LPA Calderon interviewed staff (S1-S3). Two out of three staff state that staff do not set up transportation for residents in care. S3 states that S3 does arrange transportation for R1 and S3 did not know R1 had a doctor’s appointment on 02/26/2024 and 02/28/2024. LPA Calderon interviewed residents (R1-R4). R1 states that staff did not arrange transportation for R1 doctors’ appointments, and he missed the doctors’ appointments on 02/26/2024 and 02/28/2024. Three out of four residents state that staff do help them with transportation requests. S4 could not answer any questions due to health conditions. LPA Calderon interviewed witness (W1-W3). W1 states that W1 sets up transportation request for VA hospital but does not request transportation request. W1 states that the request is made by facility staff. W2 states that their records do not show any transportation request from facility for 02/26/2024 and 02/28/2024. W3 states that R1 did have a doctor’s appointment for 02/26/2024 and 02/28/2024 and was a no show for appointments. LPA Calderon reviewed R1 admission agreement (date 09/20/2023), section #7 states “plan, arrange or book for an approved non-emergency medical transportation provider to medical and dental appointments. Reviewed transportation schedule for R1. Schedule suggest that R1 had appointments for 02/07/2024, 02/08/2024, 02/26/2024, 02/28/2024, 03/27/2024 and 05/15/2024. Reviewed transportation log notes (date 01/17/2024, 02/07/2024 and 02/08/2024), log notes support R1 appointment schedule for doctors’ appointments.

Based on LPA Calderon observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegations “facility staff did not assist resident with arranging transportation to medical appointments” is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 are cited on the attached LIC 9099D.

An exit interview was conducted, and a copy of the Complaint Report and Appeal Rights were provided to the Administrator Nelson Ortega (A1).

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 11-AS-20240227140101
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: 03/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2024
Section Cited
CCR
87208(8)
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87208 Plan of Operation (8) Transportation arrangements for persons served who do not have independent arrangements. This requirement was not met as
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Administrator will provide training to staff regarding schedualing residents doctors appointments and email LPA Calderon with proof of training by POC date.
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Based on interviews and records reviews, the facility staff failed to provide transportation to resident in care. 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: Eva M Alvarez
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 03/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024
LIC9099 (FAS) - (06/04)
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