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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602152
Report Date: 04/14/2023
Date Signed: 04/20/2023 09:39:28 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
04/03/2023 and conducted by Evaluator Lourdes Montoya
COMPLAINT CONTROL NUMBER: 11-AS-20230403091737
FACILITY NAME:SANTA FE HOME CARE IIFACILITY NUMBER:
198602152
ADMINISTRATOR:ASIS, VIRGINIAFACILITY TYPE:
740
ADDRESS:2255 SANTA FE AVENUETELEPHONE:
(424) 558-8285
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY:6CENSUS: 5DATE:
04/14/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:VIRGINIA ASISTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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9
Facility not serving residents an adequate amount of food.
Facility is not serving nutritious meals to residents.
Facility not following physician's orders.
Facility is verbally abusive towards residents.
Facility is not providing assistance to resident in care.
Facility is not providing basic essentials to residents.

INVESTIGATION FINDINGS:
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13
On 04/14/2023, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced subsequent complaint visit at this facility to obtain additional information and to deliver complaint findings. LPA was greeted by Staff Tamico Thomas. Administrator Virginia Asis arrived later and joined the visit. LPA explained the purpose of the visit.

The investigation consists of the following: On 4/11/2023, LPA Montoya interviewed three staff (S1-S3) and four residents (R1-R4). LPA was unable to complete a proper interview with R1. LPA reviewed all residents’ (R1-R5) physician’s reports and staff’s timesheets. A tour of the facility was conducted. On 4/13/2023, LPA interviewed one resident (R5) and reviewed all residents’ (R1-R5) admission agreements.

Report continued in LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
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 8
Control Number 11-AS-20230403091737
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SANTA FE HOME CARE II
FACILITY NUMBER: 198602152
VISIT DATE: 04/14/2023
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Regarding allegation: Facility not serving residents an adequate amount of food.

It was reported that food portions served are not adequate and residents are left wanting more food. LPA interviewed three staff (S1-S3) and five residents (R1-R5). LPA was unable to obtain clear response from one resident (R1) due to declining medical condition. R2 stated facility serves only one hot meal a day. Three staff (S1-S3) and two residents (R3-R4) revealed facility serves adequate amount of food to residents. R5 stated sometimes food portion served is more than enough, just enough or too little but additional food is available if requested. S2 mentioned that residents always appreciate staff for serving them with plenty of food on their plate. Based on gathered information, there is no sufficient evidence to prove that facility is not serving residents an adequate amount of food.

Regarding allegation: Facility is not serving nutritious meals to residents.



It was reported that residents are frequently given Bologna and noodles which are high in sodium and bad for those who have high blood pressure. LPA interviewed three staff (S1-S3) and five residents (R1-R5). LPA was unable to obtain clear response from one resident (R1) due to declining medical condition. R2 answered “So-so” when LPA asked whether the facility is serving nutritious meals to residents. Three staff (S1-S3) and three residents (R3-R5) revealed facility is serving nutritious meals to residents in care. S2 stated S2 prepares a balanced diet with vegetables, protein, carbs and fruits for residents. R5 revealed facility staff serve nutritious meals which include protein, rice, vegetables, fruits with nuts, and juices. Based on gathered information, there is no sufficient evidence to prove that facility is not serving nutritious meals to residents.

Regarding allegation: Facility is not following physician's orders.



It was reported that caregiver does not stick to the care plan of doctor's orders. LPA interviewed three staff (S1-S3) and five residents (R1-R5). Staff (S1-S3) denied that facility is not following physician’s order. LPA was unable to obtain clear response from one resident (R1) due to declining medical condition. When LPA asked residents if facility is not following physician’s order, R2 answered “It’s okay”, R3 said “I don’t have a doctor.”, R4 stated S2 serves R4 low sugar or sugar free diet as prescribed by the physician. Based on gathered information, there is no sufficient evidence to prove that facility is not following physician’s orders.

REPORT CONTINUED IN LIC 9099C

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 8
Control Number 11-AS-20230403091737
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SANTA FE HOME CARE II
FACILITY NUMBER: 198602152
VISIT DATE: 04/14/2023
NARRATIVE
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Regarding allegation: Facility staff is verbally abusive towards residents.

It was reported that caregiver is verbally abusive to the residents. For some residents who do not have people visiting them, they are treated without regard. LPA interviewed three staff (S1-S3) and five residents (R1-R5). LPA was unable to obtain clear response from one resident (R1) due to declining medical condition. Three staff (S1-S3) and four residents (R2-R5) denied that facility staff is verbally abusive towards residents. Based on gathered information, there is no sufficient evidence to prove that facility staff is abusive towards residents.

Regarding allegation: Facility is not providing assistance to resident in care.



It was reported that when one resident asked caregiver for water, the caregiver brought water to resident, but caregiver drank it in front of the resident and walked away. The Resident is not independent and cannot hold a cup independently. Same resident was left on the floor. LPA interviewed three staff (S1-S3) and five residents (R1-R5). LPA was unable to obtain clear response from one resident (R1) due to declining medical condition. Three staff (S1-S3) and four residents (R2-R5) denied that facility is not providing assistance to residents in care. R4 revealed S2 is good at assisting residents in care. R5 stated due to motor impairment, facility staff assist R5 in moving in and out of the wheelchair. R5 revealed staff always provide assistance to residents. Based on gathered information, there is no sufficient evidence to prove that facility is not providing assistance to residents in care.

Regarding allegation: Facility is not providing basic essentials to residents.

It was reported that facility staff are constantly asking residents’ families to provide basic essentials, such as bottled water, food and cleaning supplies. LPA interviewed three staff (S1-S3) and five residents (R1-R5). LPA was unable to obtain clear response from one resident (R1) due to declining medical condition. Three staff (S1-S3) and four residents (R2-R5) denied that facility is not providing assistance to residents in care. Three residents (R3-R5) revealed they buy their own hygiene supplies, but the facility has available basic essentials for residents. Based on gathered information, there is no sufficient evidence to prove that facility is not providing basic essentials to residents.

Based on LPA’s observation, interviews conducted, and records reviewed, the preponderance of evidence standard has not been met. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the above allegations are Unsubstantiated.

An exit interview was conducted with Administrator Virginia Asis and a copy of the report was provided.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 8
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 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
04/03/2023 and conducted by Evaluator Lourdes Montoya
COMPLAINT CONTROL NUMBER: 11-AS-20230403091737

FACILITY NAME:SANTA FE HOME CARE IIFACILITY NUMBER:
198602152
ADMINISTRATOR:ASIS, VIRGINIAFACILITY TYPE:
740
ADDRESS:2255 SANTA FE AVENUETELEPHONE:
(424) 558-8285
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY:6CENSUS: 5DATE:
04/14/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:VIRGINIA ASISTIME COMPLETED:
04:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility is unsanitary.
Facility is serving expired food to residents.
Facility is not properly cleaning dishes.
Lack of staffing
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 04/14/2023, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced subsequent complaint visit at this facility to obtain additional information and to deliver complaint findings. LPA was greeted by Staff Tamico Thomas. Administrator Virginia Asis arrived later and joined the visit. LPA explained the purpose of the visit.

The investigation consists of the following: On 4/11/, 2023, LPA Montoya interviewed three staff (S1-S3) and four residents (R1-R4). LPA reviewed all residents’ (R1-R5) physician’s reports and staff's timesheet. A tour of the facility was conducted. On 4/13/2023, LPA interviewed one resident (R5) and reviewed all residents’ (R1-R5) admission agreements.

Report continued in LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 11-AS-20230403091737
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SANTA FE HOME CARE II
FACILITY NUMBER: 198602152
VISIT DATE: 04/14/2023
NARRATIVE
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Regarding allegation: Facility is unsanitary.


It was reported that the home looked unsanitary and did not appear clean.

LPA interviewed three staff (S1-S3) and five residents (R1-R5). Three staff (S1-S3) and four residents (R2-R5) denied the facility is unsanitary. LPA was unable to obtain clear response from one resident (R1) due to declining medical condition. Based on LPA Montoya’s observations during a tour of the inside and outside grounds of the facility on 4/11/2023, kitchen floor is dirty, the bottom of the dishwasher had molded water and smelled malodorous, the laundry floor was covered with water leak, the ground of the right side of the facility is covered with molded water and white powder across the walkway. Based on gathered information, there is sufficient evidence to prove that facility is unsanitary.



Regarding allegation: Facility is serving expired food to residents.

It was reported that loaves of bread on the dining table have been there for months are served to residents in care.

LPA interviewed three staff (S1-S3) and five residents (R1-R5). Three staff (S1-S3) and four residents (R2-R5) denied the facility is serving expired food to residents. LPA was unable to obtain clear response from one resident (R1) due to declining medical condition. S2 revealed sometimes S2 checks the expiration of the food but sometimes S2 does not check the expiration because S2 has been busy working alone. Based on LPA Montoya’s observations during a tour of the inside and outside grounds of the facility on 4/11/2023, facility has expired food to residents. LPA observed the following expired food: Chicken Bolgna – expired on 2/7/2023; a bag of wheat bread – expired on March 1, 2023; a bag of white bread – expired on March 18, 2023; a bag of garden salad – expired on April 7, 2023, and lettuce looks saggy. Based on gathered information, there is sufficient evidence to prove that facility is serving expired food to residents.



Regarding allegation: Facility is not properly cleaning dishes.

It was reported that dishes are usually stacked high and not washed properly.

LPA interviewed three staff (S1-S3) and five residents (R1-R5). Three staff (S1-S3) and three residents (R2, R3 and R5) denied the facility is not properly cleaning dishes. LPA was unable to obtain clear response from one resident (R1) due to declining medical condition. R4 stated sometimes plates, cups and utensils are left overnight in the sink unwashed. LPA observed about five white plates stored in the cabinet are still wet and one of them has food residue on the edges of the plate. Based on gathered information, there is sufficient evidence to prove that facility is not properly cleaning the dishes.


SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 11-AS-20230403091737
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SANTA FE HOME CARE II
FACILITY NUMBER: 198602152
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2023
Section Cited
CCR
87303(a)(1)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This was not met as evidenced by:
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Administrator shall clean all the mentioned spaces in the home that are unsanitary.
Administrator shall submit a POC to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
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Based on LPA Montoya’s observations during a tour of the inside and outside grounds of the facility on 4/11/2023, kitchen floor is dirty, the bottom of the dishwasher had molded water and smelled malodorous, the laundry floor was covered with water leak, the ground of the right side of the facility is covered with molded water and white powder across the walkway. This poses a potential health, safety and/or personal rights risk to residents in care.
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Type B
04/21/2023
Section Cited
CCR
87555(b)(8)
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87555 General Food Service Requirements
(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This was not met as evidenced by:
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Administrator shall discard all expired food and shall ensure the facility does not serve expired food to residents. Administrator shall read Section 87555 and shall provide an in-service training to all staff. Administrator shall submit a POC to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
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Based on LPA Montoya’s observations during a tour of the inside and outside grounds of the facility on 4/11/2023, facility has expired food. LPA observed the following expired food: Chicken Bolgna – expired on 2/7/2023; a bag of wheat bread – expired on March 1, 2023; a bag of white bread – expired on March 18, 2023; a bag of garden salad – expired on April 7, 2023, and lettuce looks saggy. This poses a potential health, safety and/or personal rights risk 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.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 11-AS-20230403091737
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SANTA FE HOME CARE II
FACILITY NUMBER: 198602152
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2023
Section Cited
CCR
87555(b)(30)(31)(B)
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87555 General Food Service Requirements (b) The following food service requirements shall apply:(30) All utensils used for eating and drinking and in preparation of food and drink, shall be cleaned and sanitized after each usage.
(31) Dishes and utensils shall be disinfected:
(B) In facilities not using mechanical means, by an alternative comparable method approved by the licensing agency or by the local health department, such as the addition of a sanitation agent to the final rinse water.
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Administrator shall ensure all utensil for eating and drinking are always cleans and sanitizes. Administrator shall give staff an in-service training about this section. Administrator shall submit a POC to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
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LPA observed about five white plates stored in the cabinet are still wet and one of them has food residue on the edges of the plate. LPA observed the dishwasher is not in good repair. R4 stated sometimes plates, cups and utensils are left overnight in the sink unwashed. This poses a potential health, safety and/or personal rights risk to residents in care.
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Type B
04/21/2023
Section Cited
CCR
87413(a)(1)
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87413 Personnel - Operations
(a) In each facility: (1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This was not met as evidenced by:
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Administrator shall ensure the facility has sufficient staffing all the time. Administrator shall submit an updated LIC 500 CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
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Based on LPA’ review of staff’s timesheets and interviews conducted, there is a lack of staffing in the facility. Since January 2023 to April 2023, there were days that facility had only one staff duringd day and night. There are currently five residents in the home of which three are diagnosed with dementia. One out three residents with dementia is ambulatory, two are non-ambulatory. R3 and R5 observed only one staff (S2) is present in the facility every day and some days, another staff comes to help S2. This poses a potential health, safety and/or personal rights risk 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.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 8
Control Number 11-AS-20230403091737
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SANTA FE HOME CARE II
FACILITY NUMBER: 198602152
VISIT DATE: 04/14/2023
NARRATIVE
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Regarding allegation: Lack of staffing.

It was reported that there is only one caregiver for five (5) residents in the home.

LPA interviewed three staff (S1-S3) and five residents (R1-R5) of which 3 residents are diagnosed with dementia. Three staff (S1-S3) and one resident (R4) denied there is lack of staffing in the facility. During interviews, LPA was unable to obtain clear response from one resident (R1) due to declining medical condition; R2 did not provide answer to this interview question; R3 and R5 observed only one staff (S2) is present in the facility every day, only on some days that another staff comes to help S2. Based LPA's review of staff time sheets, since January 2023 to April 2023, there were days that facility had only one staff on duty. Based on gathered information, there is sufficient evidence to that there is lack of staffing in the facility.



Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 1,6), the following deficiency had been observed and a citation issued (ref. LIC 9099D).

An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to the Administrator Virginia Asis.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 8 of 8