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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602152
Report Date: 08/22/2024
Date Signed: 08/22/2024 06:06:33 PM

Document Has Been Signed on 08/22/2024 06:06 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
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: 4DATE:
08/22/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:19 PM
MET WITH:Sonny GaraldeTIME VISIT/
INSPECTION COMPLETED:
03:47 PM
NARRATIVE
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On 08/22/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a Plan of Correction (POC) and was met by caregiver Sonny Garalde. The purpose of the visit is to follow-up on the Plan of Correction that was due on 08/08/24 during Require Annual Inspection.

The facility had an individual working as a staff # (S1) who did not have Criminal Clearance Background and was cited for 87355(e)(1).

Based on observation, LPA was greeted by staff (S1) who still does not have a Criminal Clearance Background was observed assisting resident #1 (R1) out of the community at 3:00 pm. (S1) stated to be on-call reliever and is being paid by Santa Fe Home Care.

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 with Sonny Geralde and a copy of the Evaluation Report and Appeal Rights were provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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 08/22/2024 06:06 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 08/22/2024 at 03:17 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SANTA FE HOME CARE II
FACILITY NUMBER: 198602152

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/23/2024
Section Cited
CCR
87355(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 S1 criminal background clearance and Guardian association to the facility to ernand.dabuet@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 #1 (S1) having a criminal background clearance nor association to the facility. S1 worked in the facility on 08/22/24.
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Type B
09/05/2024
Section Cited
CCR87405(b)(2)

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87405(b)(2) Administrator - Qualifications and Duties. (b)The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. (2)Knowledge of and ability to conform to the applicable laws, rules and regulations.
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The licensee will create a plan to ensure that the administrator performs knowledge of and conforms to applicable laws, rules and regulations. Plan of correction will be submitted by POC due date: 09/05/24 to ernand.dabuet@dss.ca.gov
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This requirement was not met as evidenced by:
Based on interview and observation the Licensee/Administrator failed to adhere to Title 22 regulations, resulting to multiple deficiencies cited, which poses a potential health and safety 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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024


LIC809 (FAS) - (06/04)
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