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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602152
Report Date: 09/28/2023
Date Signed: 09/29/2023 10:44:03 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: DATE:
09/28/2023
UNANNOUNCEDTIME BEGAN:
08:07 AM
MET WITH:Virginia AsisTIME COMPLETED:
04:07 PM
ALLEGATION(S):
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Staff are not ensuring that resident receives medications as prescribed by their physician.
INVESTIGATION FINDINGS:
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On 09/28/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent complaint visit. LPA was greeted by caregiver Allan Gloriani. Gloriani 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. Interviews with staff #1-#3 (S1-S3), residents #2-#5 (R2-R5), and witnesses #1 - 3 (W1-W3). A tour of the physical plant was conducted.

Evaluation Report continues LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
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 4
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: 09/28/2023
NARRATIVE
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INVESTIGATION REVEALED THE FOLLOWING:

Allegation #6: Staff are not ensuring that resident receives medications as prescribed by their physician.

The details of the complaint alleged that resident #1 (R1) may not be receiving medications as prescribed by the physician. The complainant reported due to (R1's) health condition it is suspected the doctor's prescribed medication orders are not being followed by staff.

Service records revealed (R1) was admitted at Santa Fe Home Care II on 08/23/22 and was discharged on 09/18/23 according to administrator staff #1 (S1). (R1) was on hospice care and was being provided hospice care services twice a week. Pacific Post Acute Medical Records (dated: 08/23/22) listed (R1) was on (12) prescription medications. An interview between 10:01 am - 10:49 am with (2) out of (2) staff #2-#3 (S2-S3) confirmed that not knowing what a Medication Administrator Record (MAR) is for (R1). (S2) admitted that no medications were documented when administered to residents. (S2) confirmed that hospice did not assist with (R1's) medications and that only the staff at Santa Fe Home assisted. An interview with (S1) confirmed that staff assisted with medications for the residents and that the facility has a (MAR) on record but was unable to produce the records for the Department for review.

The Department interviewed residents between 09:02 am - 12:00 pm (2) out (5) residents handled their medications residents #2 and #5 (R2 and R5). Three residents required assistance with medications residents #1, #3, and #4 (R1, R3, and R4). Physician's Report for (R1) (dated 08/05/22) indicated (R1) is not able to manage own prescription medications or able to administer own PRN medications. An interview with (R1) was conducted on 09/15/23, however, due to (R1's) health condition (R1) was not able to hold a conversation. The facility was not able to produce evidence of hospice records, resident's progress notes or (MAR) when requested. Based on the information gathered, there is sufficient evidence to support the allegation 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.

An exit interview was conducted with Virginia Asis, Administrator, and a hard copy of the report along with appeal rights.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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: 09/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/29/2023
Section Cited
CCR
98465(c)(2)
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87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need .. medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist...(2) Once ordered by the physician the medication is given according to the physician's directions.
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Licensee shall ensure medications are administered according to PCP orders with proof of documentation. Licensee will obtain a copy of documentation noting medications were disbursed properly per PCP orders. Proof of correction receipt must be sent to by fax to 323-981-1782 attn: LPA Dabuet by 09/29/23.
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This requirement is not met as evidence by: Based on interviews, the licensee did not comply with this section. Licensee did not have evidence to show proof that prescribed medications or PRN for (R1,R3 & R4) were administered PCP orders. This poses an immediate health, safety or personal rights risks to persons in care.
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This was corrected during Case Management visit on 09/29/30.
Type B
11/10/2023
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Licensee shall ensure medications are administered according to PCP orders and that staff a trained on administering medications. The facilty will conduct a training on medications with staff. Proof of correction receipt must be sent to by fax to 323-981-1782 attn: LPA Dabuet by 10/10/23.
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This requirement is not met as evidence by: Based on interviews, the licensee did not comply with this section. Staff assisted with medications for residents without knowledge of documenting PRN or prescribed medications. Residents are not provided a safe environment. This a potential health, safety or personal rights risks 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.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC9099 (FAS) - (06/04)
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