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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602152
Report Date: 06/04/2024
Date Signed: 06/04/2024 12:20:40 PM

Document Has Been Signed on 06/04/2024 12:20 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/
DIRECTOR:		ASIS, VIRGINIAFACILITY TYPE:
740
ADDRESS:2255 SANTA FE AVENUETELEPHONE:
(424) 558-8285
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 0DATE:
06/04/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:44 AM
MET WITH:Lucy DenzellTIME VISIT/
INSPECTION COMPLETED:
12:35 PM
NARRATIVE
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On 06/04/24, Licensing Program Analyst (LPA) Regina Cloyd conducted a Case Management Health & Safety visit at the facility mentioned above. LPA was welcomed by staff Lucy Denzell and LPA called Licensee Angelique Gradney by telephone to explain the purpose of today's visit.

At 10:54 AM, Ms. Gradney explained that the facility had a sink disposal and piping problem. She indicated that the plumbing began to leak to the side of the house, into the neighbor's house, and it caused a foul odor. Ms. Gradney's first vendor was unable to resolve the problem so it resulted in a bigger project. Ms. Gradney stated that she decided to go ahead and complete the plumbing, painting, and tent the facility for termites, 06/05/24, all at once. She stated that the project started two weeks ago. Ms. Gradney confirmed that there were no residents present and notice of work and move of resident was not provide to Community Care Licensing. Resident #1 (R1) was relocated to Santa Fe Home Care Homes #198205144 on 05/13/24. Resident #2 (R2) voluntarily moved prior to the construction on 04/08/24. LPA Cloyd observed the facility being remodeled and under construction.

Based on the telephone interview and LPA observation, 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: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE: DATE: 06/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/04/2024
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 06/04/2024 12:20 PM - It Cannot Be Edited


Created By: Regina Cloyd On 06/04/2024 at 11:25 AM
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: 06/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/10/2024
Section Cited
CCR
87224(f)

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(f) A written report of any eviction shall be sent to the licensing agency within five (5) days.

This requirement is not met as evidenced by:
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The Licensee will provide a written report of Resident #1's eviction to regina.cloyd@dss.ca.gov by the POC due date.
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Based on interview and observation, the licensee did not comply with the section cited above for Resident #1 (R1) which poses a potential personal rights risk to persons in care. Licensing did not receive notice from the facility regarding R1's permanent move.
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Type B
06/19/2024
Section Cited
CCR87303(a)

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(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 requirement is not met as evidenced by:
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The Licensee will provide evidence for meeting this regulation prior to the POC due date. Plan of correction to be emailed to regina.cloyd@dss.ca.gov
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Based on interview and observation, the licensee did not comply with the section cited above which poses a potential safety and personal rights risk to persons in care. LPA observed the facility being remodeled and under construction.
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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 Coronel
LICENSING EVALUATOR NAME:Regina Cloyd
LICENSING EVALUATOR SIGNATURE:
DATE: 06/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/04/2024


LIC809 (FAS) - (06/04)
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