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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602152
Report Date: 04/14/2023
Date Signed: 04/14/2023 03:36:51 PM

Document Has Been Signed on 04/14/2023 03:36 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, 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:
04/14/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:VIRGINIA ASISTIME COMPLETED:
04:00 PM
NARRATIVE
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On 4/14/2023, Licensing Program Analyst (LPA) Lourdes Montoya conducted a case management - deficiency visit at this facility.

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

During LPA's visit on 4/11/2023 AND 4/14/2023, LPA observed all five residents' records (folders) are stored in an unlocked cabinet.


The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22.

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: 04/14/2023
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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/14/2023 03:36 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 04/14/2023 at 03:18 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: 04/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/21/2023
Section Cited
CCR
87506(c)

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87506 Resident Records
(c) All information and records obtained from or regarding residents shall be confidential.
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Administrator shall ensure all residents records are kept confidential in a locked storage. Administrator shall submit a POC to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
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During LPA's visit on 4/11/2023 AND 4/14/2023, LPA observed all five residents' records (folders) are stored in an unlocked cabinet. This poses a potential personal rights, health or safety 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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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