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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602152
Report Date: 05/04/2023
Date Signed: 05/04/2023 04:40:19 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/28/2023 and conducted by Evaluator Lourdes Montoya
COMPLAINT CONTROL NUMBER: 11-AS-20230428111619
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:
05/04/2023
UNANNOUNCEDTIME BEGAN:
08:34 AM
MET WITH:VIRGINIA ASISTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not follow safe food handling practices,
Staff did not keep resident's information confidential.
INVESTIGATION FINDINGS:
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On 5/4/2023, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced subsequent complaint visit at this facility to obtain additional information and to deliver complaint findings. LPA was greeted by Caregiver Allen Gloriani and House Manager/Caregiver Lucy Dezell. Administrator Virginia Asis arrived later and joined the visit. LPA explained the purpose of the visit.

The investigation consists of the following: On 5/3/2023, LPA obtained copies of the facility roster for residents and staff. Interviews were conducted with three staff (S1-S3) and four residents (R2-R5). LPA was unable to obtain information from two residents (R6-R7) due R6’s medical condition and R7 is in the hospital. LPA obtained and reviewed R1's service records. A tour of the facility was conducted. On 5/4/2023, LPA interviewed one resident (R1) and one witness (W1) by telephone. However, LPA Montoya was unsuccessful in attempt to conduct telephone interview with one potential witness (W2).

Report continued in LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 11-AS-20230428111619
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 II
FACILITY NUMBER: 198602152
VISIT DATE: 05/04/2023
NARRATIVE
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INVESTIGATIONS REVEALED:

Based on records review, Resident #1 (R1) was admitted to the facility on 12/4/2022 and left the facility on April 4, 2023. R1 is non-ambulatory and has a mild cognitive impairment. R1 has a special diet of low sodium and low sugar.



Regarding allegation: Staff did not follow safe food handling practices.

It was reported that cooked and uncooked food are constantly exposed. LPA Montoya conducted interviews with three staff (S1-S3), five residents (R1-R5) and one witness (W1). Based on interviews conducted, all three staff (S1-S3), and all five residents (R1-R5) denied that staff did not follow safe food handling practices. During LPA’s complaint visit on 5/3/2023 at 10:06 am until 10:16 am, LPA checked and observed several bags of bread and bags of chips were open and unsealed. LPA observed a bowl of meat, a glass container of gelatin and a soy sauce with sliced onions in the refrigerator uncovered. LPA also observed uncovered bowl of rice soup, chips and salsa near the stove oven. Based on gathered information and photos taken, there is sufficient evidence to prove that staff did not follow safe food handling practices.

Regarding allegation: Staff did not keep resident's information confidential.

It was reported that staff shared Residents’ confidential/medical information to visitors and residents’ confidential records are exposed and not locked. LPA Montoya conducted interviews with three staff (S1-S3), five residents (R1-R5) and one witness (W1). Based on interviews conducted, all three staff (S1-S3), and all five residents (R1-R5) and a witness (W1) denied that staff did not keep resident’s information confidential. During the complaint visit on 5/3/2023 at 9:52 am, LPA observed residents’ confidential files including R1’s file were not locked and accessible. LPA advised S2 to keep and lock all confidential files. At 10:38 am, LPA observed R1’s confidential file folder was still accessible and not moved to a locked storage. Based on gathered information and photos taken, there is sufficient evidence to prove that staff did not keep resident’s information confidential.

Based on interviews, observations, and supporting documentation, the preponderance of evidence standard has been met; therefore, the above allegations are found to be SUBSTANTIATED.



According to the California Code of Regulations (Title 22, Division 6, Chapter 1,6), the following deficiencies had been observed and citations issued (ref. LIC 9099D). CIVIL PENALTY ASSESSED.

An exit interview was conducted and copy of the Complaint Report and Appeal Rights were provided to the Administrator Virginia Asis.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 11-AS-20230428111619
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 II
FACILITY NUMBER: 198602152
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/12/2023
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 locked all residents' confidential information. Administrator shall give an in-service training to staff on Section 87506 of Title 22. POC to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
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During the complaint visit on 5/3/2023 at 9:52 am, LPA observed residents’ confidential files including R1’s file were not locked and accessible. LPA advised S2 to keep and lock all confidential files. At 10:38 am, LPA observed R1’s confidential file folder was still accessible and not moved to a locked storage. This poses a potential health, safety and/or personal rights risk to residents in care.
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CIVIL PENALTY ASSESSED FOR REPEAT VIOLATION (SEE 4/21/2023 for prior citation)
Type B
05/12/2023
Section Cited
CCR
8755(b)(9)
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87555 General Food Service Requireme
(b) The following food service requirements shall apply: (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.
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S2 covered all food and snacks during the visit. Administrator shall give an in-service training to staff on Section 87555 of Title 22. POC to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
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 During LPA’s complaint visit on 5/3/2023 at 10:06 am, LPA checked and observed several bags of bread and chips were open and not sealed. LPA observed a bowl of meat, a glass container of gelatin and a soy sauce with sliced onions in the refrigerator uncovered. LPA also observed uncovered bowl of rice soup, chips and salsa near the stove oven. 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.
SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3