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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198205144
Report Date: 06/08/2024
Date Signed: 06/08/2024 01:07:16 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
10/24/2022 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20221024135727
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:
06/08/2024
UNANNOUNCEDTIME BEGAN:
11:17 AM
MET WITH:Christian EspinoTIME COMPLETED:
12:28 PM
ALLEGATION(S):
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Staff neglected resident resulting in resident sustaining pressure injuries.
Staff neglected resident resulting in dehydration.
Staff neglected resident resulting in malnutrition.
Staff left resident soiled for an extended period of time.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ernand Dabuet made an unannounced visit to the facility and was greeted by a caregiver (S2: Christian Espino). LPA conducted a risk assessment before entering the facility and observed the COVID-19 protocol. S2 informed LPA that the facility has no COVID cases nor do residents or staff have symptoms. The purpose of today’s visit is to conduct a subsequent visit to deliver the findings about the above-mentioned allegation(s). LPA contacted Administrator Angelique Gradney who could not be present for this visit, authorized Christian Espino to sign for this complaint report.

The investigation consisted of the following: A 24-hour visit for health and safety check of residents in care was conducted by LPA Jeremiah Randle on 10/25/22. LPA was met by Staff #1 (S1: Rey Malit, Caregiver); as the Administrator (A1: Angelique Gradney) and Asst. Administrator (A2: Catherine Espino were unavailable. LPA conducted a tour of the facility’s physical plant and spoke to residents in care (R1-R3) and observed them sitting in the common areas with no signs of distress.
(Evaluation Report continues LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2024
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 4
Control Number 11-AS-20221024135727
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: 06/08/2024
NARRATIVE
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LPA requested pertinent documents related to the above-mentioned allegation(s): facility staff roster & work schedules (September 2022), residents’ roster (October 2022), weekly menu and photos of meals (October 2022), facility staff in-service training records (dated 07/05/22) regarding Care for Dementia, Direct Care staff, and Personal Rights; Resident #1’s face sheet, admission agreement (dated 08/30/22), physician’s report (dated 08/26/22), appraisal/needs and services plan (dated 08/30/22), medication records (09/29/22), Allied Hospice Care records (dated 09/28/22), hospice flow chart with sign-in/sign-out sheet (dated 09/29/22, 09/30/22, 10/19/22), and Kaiser Permanente Medical Nutritional Therapy Assessment (dated 10/24/22).

This complaint investigation was referred to the California Department of Social Services (CDSS), Community Care Licensing Division (CCLD), Investigations Bureau (IB) and assigned to Investigator Laura Garcia. It included a review of Resident #1’s medical records from Kaiser Permanente Medical Center (dated 10/21/22); interviews with facility staff (A1, S1), residents (R1 – R3), witnesses (W1 – W5) from local law enforcement agency (Torrance Police Dept), hospital personnel (Kaiser Permanente), and hospice staff (Allied Hospice Care). After several attempts to contact Witness #3 (Palliative Physician), Witness #4 (KP Physician), and Witness #5 (Kaiser Permanente Social Worker); to date, no contact was made possible. Attempted interviews with residents (R1 – R3) were not possible due to their cognitive disorders and inability to answer questions. Resident #4 was unavailable for an interview due to their hospitalization.

INVESTIGATION REVEALED THE FOLLOWING:


Regarding Allegation #1: this investigation revealed that Resident #4 belonged to a Permanent Housing Program for the Elderly under Kaiser Permanente. The resident was under hospice care (effective 09/28/22); specifically for palliative care and comfort while at the facility. Resident #4 was medically re-assessed by the registered nurse (Witness #1) who visited the facility every other day and would evaluate Resident #1 for any type of food/fluid intake. RN suggested to facility staff to continue offerings of liquids and meals; of which, facility staff complied with the hospice nurse’s directives.

Based on the evidence gathered and interviews conducted, and records reviewed, 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; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Staff neglected resident resulting in resident sustaining pressure injuries is found to be UNSUBSTANTIATED.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 11-AS-20221024135727
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: 06/08/2024
NARRATIVE
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Regarding Allegation #2: this investigation revealed facility staff were instructed to provide adequate liquids despite Resident #4 having difficulty swallowing. Specific instructions were given by Witness #1 to offer the resident nutritional liquids. Facility staff were instructed to immediately inform the hospice nurse (Witness #1) of any change of condition in the resident. Facility staff were aware of Resident #4’s decreased intake of fluids and to prevent dehydration, they would consult with Witness #1 for other nutritional liquid options. Resident #4 would self-induce regurgitation behaviors right after ingesting liquids; and, facility staff would re-direct the resident’s behaviors. During Witness #1’s evaluation visits with Resident #4, the Hospice RN would observe facility staff offer the resident nutritional fluids throughout the day.

Based on the evidence gathered and interviews conducted, and records reviewed, 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; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Staff neglected resident resulting in dehydration is found to be UNSUBSTANTIATED.

Regarding Allegation #3: this investigation revealed facility staff were instructed to provide adequate food despite Resident #4 having difficulty swallowing food. Specific instructions were given by Witness #1 to offer the resident nutritional foods. Facility staff were instructed to immediately inform the hospice nurse (Witness #1) of any change of condition in the resident. Facility staff were aware of Resident #4’s decreased intake and to prevent malnutrition, they would consult with Witness #1 for other nutritional options. Resident #4 would self-induce regurgitation behaviors and bring out undigested food after ingestion; and, facility staff would redirect the resident’s behaviors. During Witness #1’s evaluation visits with Resident #4, the Hospice RN would observe facility staff offer the resident nutritional meals throughout the day.

Based on the evidence gathered and interviews conducted, and records reviewed, 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; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Staff neglected resident resulting in malnutrition is found to be UNSUBSTANTIATED.

Regarding Allegation #4: this investigation revealed that Resident #4 was presented to the ER at Kaiser Permanente South Bay Hospital by Witness #2 (responsible person/family member) and admitted on 08/15/22. At that time, Resident #4 was observed to be covered in feces and urine per Witness #5 Resident #4 was discharged on 09/29/22 back to the facility.

(Evaluation Report continues LIC 9099-C)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 11-AS-20221024135727
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: 06/08/2024
NARRATIVE
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Interview conducted of Asst. Administrator (A2) indicated that Resident #4’s under hospice care, specifically for palliative care and comfort through Kaiser Permanente’s Housing Program for homeless, elderly residents. During Witness #1’s evaluation visits with Resident #4, facility staff would act accordingly and immediately tend to the resident’s needs. Witness #1 stated that Resident #4 would pick themself to defecate, and facility staff would immediately clean the resident’s feces off their person and bed rails. Witness #1 observed facility staff to provide the appropriate level of care for Resident #4 and denied neglect or lack of care on their behalf. Witness #2 (responsible person/family member) did not address areas of concern to facility staff regarding Resident #4 being left soiled for an extended period during their visits to the facility.

Based on the evidence gathered and interviews conducted, and records reviewed, 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; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Staff left resident soiled for an extended period of time is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report was provided to caregiver (Christian Espino).

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 06/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4