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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198205144
Report Date: 01/10/2024
Date Signed: 01/10/2024 08:45:40 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
01/03/2024 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240103085600
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:
01/10/2024
UNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Rey Malit & Algelique GradneyTIME COMPLETED:
05:17 PM
ALLEGATION(S):
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9
Staff does not ensure resident health care needs are being met.
INVESTIGATION FINDINGS:
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13
On 01/10/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial complant investigation visit at the facility. LPA was greet by care staff Rey Melit who contacted administrator Angelic Gradney by telephone. LPA explained the purpose of the visit is investigate on the allegation mentioned above.

Investigation consisted of the following: A review of resident and staff roster. A review of resident #1-#4 (R1-R4) service files including Centrally Store Medications and Medication Administration Records. Copies of (R1's) Admission Agreement, ID & Emergency Info, Resident Appraisal, Physicians Report , and other records associated with the nature of his complaint. A tour of the faciliy was performed.

(Evaluation Report continues LIC 9099)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
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 6
Control Number 11-AS-20240103085600
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: 01/10/2024
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: Staff does not ensure resident health care needs are being met.
It is alleged that the facility does not ensure resident health care needs are being met. Resident #1(R1)'s healthcare needs are not being met, according to the complainant. The complainant did not provide further details on the matter and was not available for further statements.

On 01/10/24 from 11:15 am to 12:13 pm, the Department interviewed (3) out of (4) residents #1-#3 all verified their healthcare needs were being met. (R1-R3) all verified to have received adequate care and supervision to maintain physical, mental, or emotional well-being. (R1-R3) verified medication administration by staff is received daily and timely.

On 01/10/24 from 10:31 am - 3:02 pm, the Department conducted a review of all resident service files including Medication Administration Records (MAR). Records revealed the facility failed to maintain an accurate (MAR) for January 2024. (R1-R4) all had prescribed medication and "pro re nata" (PRN). (R1) had two (2) PRN, (R2) had (1) PRN, (R3) had (2) and (R4) had (2) PRN, and (3) non-prescribed medications that were not documented in medication record. The non-prescribed medications not issued by a primary care physician were Fluticasone and Synthroid for (R4).

At 10:31 am - 10:41, staff #2 (S2) was interviewed. (S2) admitted to have failed to keep accurate records of resident's medications. (S1-S2) recognized that by not maintaining accurate records endangers residents' health and the needs are not being met. (R4) was present at the facility but was not available for an interview during this investigation visit. 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,

Deficiencies are issued and an exit interview is conducted with Rey Melit. A copy of this report and appeal rights were provided.
Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) is cleared. *
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
01/03/2024 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20240103085600

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:
01/10/2024
UNANNOUNCEDTIME BEGAN:
08:58 AM
MET WITH:Rey Malit & Angelique GradneyTIME COMPLETED:
05:17 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff does not assist resident with incidental medical needs.
INVESTIGATION FINDINGS:
1
2
3
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5
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7
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9
10
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13
On 01/10/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial complant investigation visit at the facility. LPA was greet by care staff Rey Melit who contacted administrator Angelic Gradney by telephone. LPA explained the purpose of the visit is investigate on the allegation mentioned above.

Investigation consisted of the following: A review of resident and staff roster. A review of resident #1-#4 (R1-R4) service files including Centrally Store Medications and Medication Administration Records. Copies of (R1's) Admission Agreement, ID & Emergency Info, Resident Appraisal, Physicians Report , and other records associated with the nature of his complaint. A tour of the faciliy was performed.

(Evaluation Report continues LIC 9099)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
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 6
Control Number 11-AS-20240103085600
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: 01/10/2024
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #2: Staff does not assist residents with incidental medical needs.
The details of this complaint reported that resident # 1 (R1) was being denied a care provider. The complainant did not provide further details on the matter and was not available for further statements.

On 01/10/24 from 10:31 am - 12:47 pm, the Department interviewed (3) out of (3) staff #1 -#3 all verified that all residents were being assisted with incidental medical needs. (S1) stated that resident (R1-R3) are independent and make their own medical or dental appointments. (R3) is currently on home health assistance three days a week and is being assisted by facility staff as well. According to (S1-S3), (R1 and R3) medical providers are through the Department of Veterans Affairs (VA). (S1) claimed (R1) makes all the medical appointments directly with the (VA). The (VA) notifies the Santa Fe home care office one week in advance and the office staff will generate a written confirmation to the facility with details of the upcoming appointment. The notice includes all the pertinent information such as date, time, place, transportation company, and VA coordinator information. The facility staff acts as a liaison between the resident and the medical provider. (S1) stated the facility staff has never been denied care assistance to (R1). Additional care assistance such as home health would have to be authorized by (R1's) medical physician at the VA.

On 01/10/24 from 11:15 am - 12:13 pm, the Department interviewed (3) out of (4) residents #1-#3 all verified are capable of handling their own incidental medical needs. (R1-R3) stated that they had no issues or concerns getting assistance with help with medication or physician care. (R1) claimed (R1) was not denied a care provider. (R1) claimed not to have problems contacting (VA) physicians for medical appointments and that the facility ensures that (R1's) appointments are maintained in order. (R1) stated in an interview conducted by Licensing Program Analyst (LPA) Socorro Leandro on 12/21/23, was asked about Incidental Medical/Dental Care and if needed medical assistance do I get it? (R1) stated my answer has not changed, it still a "YES". (R4) was present at the facility but was not available for an interview.

On 1/10/24 from 1:10 pm - 2:40 pm, the Department interviewed (2) out (2) family representative witness #1-#2 (W1-W2) who were complimentary of staff and that the facility provided adequate care and supervision. (W1-W2) stated residents are assisted with incidental medical needs.
(Evaluation Report continues LIC 9099-C)
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20240103085600
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: 01/10/2024
NARRATIVE
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Based on the information provider, an inspection of the facility, observation, interviews, and analysis of service records, 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 with Rey Melit, and a copy of the report was provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20240103085600
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: 01/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/11/2024
Section Cited
CCR
87465(d)(3)
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Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication... facility staff designated by the licensee shall be permitted to assist... the resident with self-administration...(3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.
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Licensee will submit plan informing the department what steps will take in effect in order to prevent documentation and medication errors from occurring. Proof of correction must be submitted by due date: 01/11/24 to LPA's email: ernand.dabuet@dabuet@dss.ca.gov
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This requirement was not met as evidenced by:
Based on interviews and records reviews, the licensee failed to make accurate records for prescribed & PRN medications from 01/01/24 - 01/10/24. (see LIC9099-C) for full details. This violation poses a immediate health, safety, or personal rights risk to persons in care.
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Type B
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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: 01/24/24 to LPA's email: ernand.dabuet@dabuet@dss.ca.gov
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This requirement was not met as evidenced by:
Based on interviews and records reviews, the licensee maintained non-prescribed medications for (R3). 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.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (424) 544-1027
LICENSING EVALUATOR NAME: Ernand DabuetTELEPHONE: (323) 629-5526
LICENSING EVALUATOR SIGNATURE:

DATE: 01/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/10/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6