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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602152
Report Date: 08/08/2024
Date Signed: 08/08/2024 04:10:50 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 08/08/2024 04:10 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: 2DATE:
08/08/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Caregiver Mignon DiazTIME COMPLETED:
04:30 PM
NARRATIVE
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On 08/08/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an annual continuation and met with Caregiver Mignon Diaz. LPA Cloyd spoke with Administrator Virginia Asis over the phone.

The facility is licensed to serve clients aged 60 and over, six non-ambulatory. They have an approved Hospice Waiver for six residents. Annual Fees are current.



The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) bedrooms, 2 bathrooms, living room, kitchen, dining room, family room, garage, and a shaded area.

On 08/07/24, the Caregiver and Administrator accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed.

Resident bedrooms had the required bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Continue to LIC809-C.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
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 4


Document Has Been Signed on 08/08/2024 04:10 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 II
FACILITY NUMBER: 198602152

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/07/2024
Section Cited
CCR
87303(e)(3)

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(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
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The staff adjusted the water heater and on 08/08/24, LPA Cloyd measured the water teamperature to be at 112 degree F. The Licensee will create a water temperature log for monthly readings and will email it to regina.cloyd@dss.ca.gov.
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Based on observation, the licensee did not comply with the section cited above in one bathroom which poses an immediate safety risk to persons in care. LPA Cloyd measured the water temparture at 142.8 degrees F.
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Type A
08/09/2024
Section Cited
CCR87355(e)(1)

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(e) All individuals subject to a criminal record review... shall prior to working... in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or... This requirement is not met as evidenced by: Based on record review, the licensee did
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The Licensee will email R5's criminal background clearance and Guardian association to the facility to regina.cloyd@dss.ca.gov by the POC due date. The Licensee will esnure that all staff complete their background checks and are associated to the desginated facility.
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not comply with the section cited above for one staff which poses an immediate safety risk to persons in care. LPA did not observe staff #5 (S5) having a criminal background clearance nor association to the facility. S5 worked in the facility on 08/07/24 and 08/08/24
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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: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:
DATE: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/08/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 II
FACILITY NUMBER: 198602152
VISIT DATE: 08/08/2024
NARRATIVE
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Common areas were clean and clear of hazards, doorways were free of obstructions.

LPA toured the kitchen area and observed knives and toxics were kept in locked storage cabinet. First Aid kit was available. One fire extinguisher, last serviced August 11, 2023 was observed in the kitchen area. Staff tested the smoke detectors in the house. Device was functional.

Two (2) resident records were reviewed and, 2 out of 2 resident records had medical assessments. Two residents’ medication was reviewed.

Four (4) staff records were reviewed.

Deficiencies are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. A violation regarding criminal record clearance warrants an immediate civil penalty of $500.00 and is hereby assessed, see LIC421IM.

On 08/07/24, LPA Cloyd did not observe Staff #5’s (S5) health screening with TB results nor criminal record clearance and association to the facility. The facility did not have a personnel record on site for S5. S5 was working at the facility on 08/07/24 and 08/08/24.

On 08/07/24, during record review, LPA did not observe an allowable health care plan for resident #1 (R1). Interviews confirmed that R1 requires assistance with injections from the Home Health Nurse and from the staff.

On 08/07/24, during the facility tour, LPA measured water temperate at 142.8. Staff adjusted the water temperature on 08/07/24 afternoon..

Continue to LIC809C.

SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:

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

DATE: 08/08/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 II
FACILITY NUMBER: 198602152
VISIT DATE: 08/08/2024
NARRATIVE
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An exit interview was conducted , plans of Correction were developed, technical assistance provided, and a copy of this report and appeals was discussed with Administrator Virginia Asis and left with Caregiver Mignon Diaz.
SUPERVISOR'S NAME: Ulysses CoronelTELEPHONE: (323) -40-7397
LICENSING EVALUATOR NAME: Regina CloydTELEPHONE: 323-981-7155
LICENSING EVALUATOR SIGNATURE:

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

DATE: 08/08/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4