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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602152
Report Date: 09/29/2023
Date Signed: 09/29/2023 10:43:08 PM

Document Has Been Signed on 09/29/2023 10:43 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:
09/29/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:34 PM
MET WITH:Lucy A DezellTIME COMPLETED:
04:04 PM
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On 09/29/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a case management inspection visit at this facility. LPA met with House Manager Lucy A. Dezell and explained the purpose of the visit.

During an investigation visit on 09/29/23 associated with complaint #11-AS-20230911101639, LPA, was informed that hospice file records for resident #1 (R1) were not available. LPA was informed by administrator Virginia Asis that (R1) was no longer a resident and was uncertain of the date when (R1) was discharged and had to confirm with the business office. The facility did not have discharge paperwork available nor hospice file and Medication Administration Records (MAR) for all residents. The facility did not have available during the investigation visit on 09/14/23 and 09/28/23 a Personnel Report LIC 500 was not provided.

Based on the information provided by the administrator, the facility violates the California Code of Regulations (Title 22, Division 6, Chapter 8), deficiencies were observed, and citations were issued (ref. LIC 9099-D).

An exit interview was conducted and a copy of the Evaluation Report and Appeal Rights were provided to Lucy Denzell.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2023
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 09/29/2023 10:43 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 09/29/2023 at 01:46 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: 09/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2023
Section Cited
CCR
8706(a)

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87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.
This requirement is not met as evidence by:
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The licensee will ensure records for all residents are current and maintained for each resident in the facility and available to CCL during visits. LIcensee will obtain copies of hospice records and (MAR) for (R1). Proof of correction must be sent by due date 10/10/23.
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Based on observation and interview, Licensee failed to provide resident records for (R1) hospice records and Medicaiton Administration Record during visits. This poses a potential health and safety risk to residents in care.
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Type B
10/10/2023
Section Cited
CCR87405(1)(2)

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 87405 Administrator - Qualifications and Duties (b) The administrator of a facility.. shall have the responsibility and authority to carry out the policies... (1) Knowledge of the requirements for providing care and supervision... (2) Knowledge of and ability to conform to the applicable laws, rules, and regulations
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Licensee shall read Title 22, Section 87405 “Administrator - Qualifications and Duties” and send a written statement to CCLD that you have read and understand this section. This plan is due to CCLD/El Segundo ASC Office by POC date of 10/10/23.
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This requirement was not met as evidenced by: Based on observation record and interviews, the Administrator failed to adhere to Title 22 regulations, resulting to multiple deficiencies cited. This violation poses/posed a potential health, safety, or personal rights risk to persons 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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/29/2023 10:43 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 09/29/2023 at 02:32 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: 09/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2023
Section Cited
CCR
87412(e)

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87412 Personnel Records (e) In all cases, personnel records shall demonstrate adequate staff coverage necessary for facility operation by documenting the hours actually worked.
This requirement is not met as evidence by:
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The licensee will ensure records for all residents are current and maintained for each resident in the facility and available to CCL during visits. LIcensee will obtain copies LIC 500. Proof of correction must be sent by due date 10/10/23.
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Based on observation and interview, Licensee failed to provide personnel report LIC 500 during visits. Uncertain of adequate staff coverage. This poses a potential health and safety risk to residents in care.
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This citation was correction during visit. A copy of LIC 500 provided.

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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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023


LIC809 (FAS) - (06/04)
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