<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602152
Report Date: 09/14/2023
Date Signed: 09/14/2023 03:21:10 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
09/11/2023 and conducted by Evaluator Ernand Dabuet
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230911101639
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:
09/14/2023
UNANNOUNCEDTIME BEGAN:
09:01 AM
MET WITH:Lucy A Dezell & Virginia AsisTIME COMPLETED:
02:35 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not ensuring that facility is free of pests.
Staff are not following safe food handling practices.
Facility has expired food.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 09/14/23 Licensing Program Analyst (LPA) Ernand Dabuet conducted an initial complaint visit. LPA was greeted by House Manager Lucy Dezell. Dezell contacted Virgina Asis who later was present during the visit LPA explained the purpose of today's visit is gather information for the allegations mentioned above.

The investigation consisted of the following: LPA obtained copies of the roster for residents and staff. Service records for resident #1 (R1), and other pertinent documents associated with this complaint. Photographs were taken during the plant inspection of the faciltiy.

Evaluation Report continues LIC 9099-C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
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 6
Control Number 11-AS-20230911101639
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: 09/14/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
INVESTIGATION REVEALED THE FOLLOWING:

Allegation #1: Staff are not ensuring that facility is free of pests.

The details of the complaint alleged the facility does not ensure the residential home is free from pests. The complainant reported that pests were observed in the kitchen and resident rooms.

On 09/14/23 between 9:00 am -11:00 am, the Department conducted a plant inspection of the entire residential home. The Department observed ants inside the refrigerator at 9:57 a.m. Additional pests were identified outside the perimeter of the refrigerator along with residue of dead ants or pest droppings. Flies were observed around the kitchen sink area.

The Department inspected each resident's room, bathrooms, activity room, dining area, outside patio area, and garage and did not observe any pests in these spaces. Based on the information gathered, there is sufficient evidence to support the allegation mentioned above.

Allegation #2: Staff are not following safe food handling practices.
Allegation #3: Facility has expired food.

In the complaint, the facility is alleged to not handle food in a safe manner. The complainant reported food is left on kitchen counters that are improperly stored and is retaining expired food items.

On 9/14/23 between 9:00 am - 11:00 am, the Department identified (10) food items with expired dates stored inside the refrigerator and food pantry. The following were identified with expired dates:(1) Creamy Peanut Butter, (1) Furman Spaghetti Can Sauce, (1) Kraft Thousand Island Dressing, (1) Daisy Sour Cream, (1) Mustard Spread, (1) Zito Salad Dressing, (1) Ragu Spaghetti Bottle Sauce, (1) Ensure Plus, (1) I Can Not Believe It's Not Butter, and (1) Crema Mexicana Table Cream.

The Department observed unsafe practices in handling food items for residents contained in the refrigerator and inside the food pantry. These food items were not stored properly to prevent harmful bacteria, viruses, parasites, contamination or chemical substances.
(Evaluation Report continues LIC 9099-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 11-AS-20230911101639
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: 09/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2023
Section Cited
CCR
87303(a)
1
2
3
4
5
6
7
87303 Maintenance and Operation (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 evidence by:
1
2
3
4
5
6
7
Licensee shall ensure all spaces in the residential facilty clean, sanitary and safe free from pest at all time. Licensee will obtain for pest control to spray interior and exterior of the facility. Proof of correction receipt must be sent to by fax to 323-981-1782 attn: LPA Dabuet by 10/10/23
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with this section. LPA observed ants, pest droppings, dead pest inside the refrigerator and the outside perimeter of the appliance. This poses a potentieal health, safety or personal rights risks to persons in care.
8
9
10
11
12
13
14
*Civil Penalty - Repeat Violation*
Type B
09/28/2023
Section Cited
CCR
87555(b)(8)
1
2
3
4
5
6
7
87555 General Food Service Requirements (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.
This requirement is not met as evidence by:
1
2
3
4
5
6
7
Licensee shall discard all expired food and shall ensure the facility does not serve expired food to residnents. Licensee shall read Section 87555 and shall provide an in-service training to all staff. Proof of correciton must be faxt to 323-981-1781 attn: LPA Dabuet by 10/10/23.
8
9
10
11
12
13
14
Based on observation, the licensee did not comply with this section. LPA observed (10) food items that had expired dates. This poses a potentieal health, safety or personal rights risks to persons in care.
8
9
10
11
12
13
14
*Civil Penalty - Repeat Violation*
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: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 11-AS-20230911101639
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: 09/14/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2023
Section Cited
CCR
87555(b)(9)(28)
1
2
3
4
5
6
7
87555 General Food Service Requirements (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service. (28) All food shall be protected against contamination...
This requirement is not met as evidence:
1
2
3
4
5
6
7
LIcensee will adhere to Section 87555 and ensure that all food items are handled safely, and stored in food storage containers for preparation and service. Licensee will read provide an in-serice training to all staff. Proof of correction must be sent by fax to 323-981-1781 attn: LPA Dabuet by 10/10/23.
8
9
10
11
12
13
14
Based on observation, LPA identified unsafe practices of food items not stored properly in refridgerator and pantry free from contamination, harmful bacteria, viruses, parasites, or chemical substances. This poses a potential health, safety and/or personal rights risks to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 11-AS-20230911101639
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: 09/14/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
An uncovered gelled Jello with no plastic wrap was stored in the refrigerator, (2) celery heads not completely wrapped in foil or stored in a plastic seal bag in the refrigerator crisper, and (3) opened box cereals were not stored in air-tight containers. Based on the information gathered, there is sufficient evidence to support the allegations mentioned above.

Based on observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D.

Exit interview was conducted with Virginia Asis, Administrator and a hard copy of the report along with appeal rights.

*Immediate Civil Penalties Issued*

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6