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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602152
Report Date: 05/03/2023
Date Signed: 05/03/2023 04:23:48 PM

Document Has Been Signed on 05/03/2023 04:23 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: 6DATE:
05/03/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:VIRGINIA ASIS/LUCY DEZELLTIME COMPLETED:
04:30 PM
NARRATIVE
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On 5/3/2023, 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:

Around 10:02 am, LPA observed two pairs of scissors and a knife on a dish drying rack in the kitchen and the drawer for sharp items was kept open and accessible. LPA observed a shovel in the backyard next to a storage shed; Around 10:20 am, LPA observed a cabinet (under the sink) for storing cleaning supplies (Cloralen, raid, fabulous, etc ) was open and accessible. Around 10:25 am, LPA observed a trowel and a large black rake in the backyard next to the sliding door. Around 11:45 am, LPA observed lysol, laundry soap and fabric softener in the laundry room were accessible.



At around 10:23 am, LPA Montoya observed the right side gate is locked with a padlock.

There is no sufficient lighting in bedrooms #2 and #3.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. CIVIL PENALTY 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: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/03/2023
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 05/03/2023 04:23 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 05/03/2023 at 02:46 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: 05/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/04/2023
Section Cited
CCR
87705(f)(1)(2)

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(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). (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This was not met as evidenced by:
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Staff (#2) moved the sharp and toxic items in a locked storage inaccessible to resident with dementia.

Administrator shall read Section 87705 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.
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Based on record review, observation and interviews, the licensee failed to ensure items that could constitute a danger to residents with dementia are inaccessible. Around 10:02 am, LPA observed two pairs of scissors and a knife on a dish drying rack in the kitchen and the drawer for sharp items was kept open and accessible. LPA observed a shovel in the backyard next to a storage shed; Around 10:20 am, LPA observed the cabinet for storing cleaning suppplies (Cloralen, etc ) was open and accessible. Around 10:25 am, LPA observed a trowel and a large black rake in the backyard next to the sliding door. Around 11:45 am, LPA observed lysol, laundry soap and fabric softener in the laundry room were accessible. This poses an immediate health, safety and/or personal rights risk to residents in care with dementia.
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CIVIL PENALTY ASSESSED.
Type B
05/12/2023
Section Cited
CCR87468.1(a)(6)

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. This was not met as evidenced by:
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Administrator removed the padlock and will ensure the side gate is always unlocked.
Administrator shall read Section 87468.1and 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.
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At around 10:23 am, LPA Montoya observed the right side gate is locked with a padlock. 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.
SUPERVISOR'S NAME:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/03/2023 04:23 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 05/03/2023 at 03:19 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: 05/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2023
Section Cited
CCR
87307(a)

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(a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents, staff, and others who may reside in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. The resident may provide the following items; however, if the resident is unable or chooses not to provide them, the licensee shall assure provision of: (B) Bedroom furniture, which shall include, for each resident, a chair, night stand, a lamp, or lights sufficient for reading, and a chest of drawers.
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Administrator shall provide more lightings for room #2 and room #3.

POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
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Based on observation and interview, there is no sufficient lighting in bedrooms #2 and #3.
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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: 05/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023


LIC809 (FAS) - (06/04)
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