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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602152
Report Date: 04/11/2023
Date Signed: 04/12/2023 08:30:25 AM

Document Has Been Signed on 04/12/2023 08:30 AM - 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, 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: 5DATE:
04/11/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:VIRGINIA ASISTIME COMPLETED:
04:00 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 4/11/2023, Licensing Program Analyst (LPA) Lourdes Montoya conducted a case management - deficiency visit at this facility.

During an unrelated complaint visit, LPA observed the following deficiencies.

A staff (S1) who is not fingerprinted was observed working in the facility. S1 admitted to LPA that he started working as a caregiver at this facility on 4/4/2023. S1 disclosed that he worked on 4/4/23, 4/5/2023, 4/6/2023 and 4/11/2023.

LPA observed the facility is in disrepair (see LIC 809D for details).

LPA observed one resident (R1) who has dementia sitting at the back patio and a couple of shovels and a rake are leaning against the wall next to the patio.


The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Civil penalties assessed.

Exit interview conducted. Appeal rights and a copy of this report was provided to Administrator Virginia Asis.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2023
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 3
Document Has Been Signed on 04/12/2023 08:30 AM - It Cannot Be Edited


Created By: Lourdes Montoya On 04/11/2023 at 01:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 04/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/12/2023
Section Cited
CCR
87355(e)(1)

1
2
3
4
5
6
7
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department. This was not met as evidenced by:
1
2
3
4
5
6
7
Administrator shall read Section 87355(e)(1) and shall self-certify understanding of the regulations and shall commit to comply. POC shall be submitted to CCLD via email to Lourdes.montoya@dss.ca.gov by the POC due date.
8
9
10
11
12
13
14
Based on record review, observation and interviews, the licensee failed to ensure S1 is fingerprint clear prior to working. S1 started working as a caregiver in this facility on 4/4/2023. This poses an immediate health, safety and/or personal rights risk to residents in care.
8
9
10
11
12
13
14
Type A
04/12/2023
Section Cited
HSC87705(f)(1)

1
2
3
4
5
6
7
(f) The following shall be stored inaccessible to residents with dementia:
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This was not met as evidenced by:
1
2
3
4
5
6
7
Administrator shall read Section 87705(f)(1) and shall self-certify understanding of the regulations and shall conduct an in-service training to all staff. POC shall be submitted to CCLD via email to Lourdes.montoya@dss.ca.gov by the POC due date.
8
9
10
11
12
13
14
Based on record review, observation and interviews, the licensee failed to ensure items that could constitute a danger to residents with dementia are stored inaccessible. LPA observed R1 who has dementia sitting at the back patio and a couple of shovels and a rake are accessible at the patio. LPA observed the cabinet under the sink where cleaning supplies such as bleaches, glass cleaner, etc. are stored is unlocked and accessible to residents with dementia.
8
9
10
11
12
13
14
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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/12/2023 08:30 AM - It Cannot Be Edited


Created By: Lourdes Montoya On 04/11/2023 at 03:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 04/11/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/14/2023
Section Cited
CCR
87303(a)

1
2
3
4
5
6
7
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. This was not met as evidenced by:
1
2
3
4
5
6
7
Administrator shall ensure that the facility is always clean, safe, sanitary and in good repair. Administrator shall submit a POC for all the mentioned deficiencies to CCL via email to lourdes.montoya@dss.ca.gov by the POC due date.
8
9
10
11
12
13
14
Based on observations and interviews, the facility is in disrepair. The diswasher is broken and has malodorous smell, the back door is rotted, the floor in the laundry room is covered with water due to a leak, the outdoor patio is covered with dried leaves, the lock of the right side gate is not working properly and the kitchen floor and oven are dirty.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2023


LIC809 (FAS) - (06/04)
Page: 3 of 3