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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198205144
Report Date: 04/17/2024
Date Signed: 04/17/2024 12:14:34 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/09/2024 and conducted by Evaluator Regina Cloyd
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240409084401
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: 5DATE:
04/17/2024
UNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Caregiver Carmelita Bonifacio.TIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did meet resident's dietary needs.
INVESTIGATION FINDINGS:
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On 04/17/2024 Licensing Program Analyst (LPA) Regina Cloyd conducted a complaint investigation at the above facility to address the following allegation(s). LPA met with Caregiver Carmelita Bonifacio. and explained the purpose of the visit. LPA spoke with Administrator Angelique Gradney over the phone.

The investigation consisted of the following: During today’s investigation, LPA toured the kitchen area, conducted record review, and interviewed residents and staff.

Continue to LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
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-20240409084401
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/17/2024
NARRATIVE
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The investigation revealed the following: Regarding the allegation "Staff did meet resident's dietary needs,” it is being alleged that although staff has been informed multiple times that R1 does not eat pork, staff is serving pork to R1. Interviews conducted indicate the following: staff is aware of the dietary needs of the residents and considers the religious background and food habits of R1. LPA observed R1 eating beef, mash potatoes with gravy, and diced apples for lunch. Physician Report and Preplacement and Resident appraisals reveal that R1 is on a special diet and does not eat pork. LPA observed a photo of the meal that R1 stated was pork but confirmed it to be chicken adobo. Based on the interviews, record review, and observations, the Department found no evidence to support the allegation mentioned above. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, as a result, the allegation is Unsubstantiated.

An exit interview was conducted, and a copy of the Complaint Report was provided to Caregiver Carmelita Bonifacio.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5