<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602152
Report Date: 12/13/2023
Date Signed: 12/13/2023 04:32:33 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 12/13/2023 04:32 PM - It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 IIFACILITY NUMBER:
198602152
ADMINISTRATOR:ASIS, VIRGINIAFACILITY TYPE:
740
ADDRESS:2255 SANTA FE AVENUETELEPHONE:
(424) 558-8285
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 4DATE:
12/13/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:19 AM
MET WITH:James OkeuhieTIME COMPLETED:
04:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/12/23, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual continuation visit to complete file reviews and medication review. LPA met with Caregiver, James Okeuhie, and explained the purpose of todays visit. During the time of visit there were four (4) residents present.
Safety LPA observed smoke and carbon monoxide detectors to be operable. The last emergency drill was conducted on 09/23/23. LPA observed a fully charged fire extinguisher last serviced on 02/10/23. LPA observed a fully stocked First Aid Kit with a manual. LPA observed all required signs posted within the facility.
Medications LPA observed Centrally Stored Medications secured in a locked cabinet in the kitchen and are inaccessible to residents. LPA reviewed Centrally Stored Medications for three residents and the Medication Administration Record (MAR) for those residents. LPA found that medications administered is consistent with documented records.
Files/Interviews LPA reviewed resident files and observed the following documents missing from Resident R1’s file a Physicians Report (Medical Assessment) with a Tuberculosis (TB) test. LPA observed Resident’s R2-R4 files had the required documents. Interviews with Resident (R1-R4) four out of four stated their needs are met and they are cared for by staff. LPA reviewed Staff (S1-S3) file and found they contained the required documents, certification, and training. LPA interviewed Staff and they were able to answer questions regarding resident care, policy, procedure, and personal rights. LPA reviewed and received a copy of the facilities Liability Insurance which expires on 08/19/24.
Infection Control During today’s visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed required infection control signs posted throughout the facility. LPA observed a 30-day supply of PPEs stored in the closet.

During today visit, per Title 22, two deficiencies were cited, please see attached LIC809-D

An exit interview was conducted with Caregiver, James Okeuhie, and a copy of this report will be provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1