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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602152
Report Date: 05/06/2024
Date Signed: 05/07/2024 01:45:26 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
06/26/2023 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 11-AS-20230626162504
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: 2DATE:
05/06/2024
UNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:Rey MalitTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff did not dispense medication as prescribed
Staff did not provide resident with special diet according to resident’s health care needs
INVESTIGATION FINDINGS:
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On 05/06/24, Licensing Program Analyst (LPA), Wendy Gibbs conducted a subsequent visit to the facility listed above to deliver findings for a complaint. LPA met with care staff Rey Malit, and the purpose of today’s visit was explained. During today’s visit there were two residents present.

During today’s visit, LPA toured the facility and reviewed the report with staff.
On a previous visit conducted on 06/27/23, LPA toured the facility, interviewed staff S1, interviewed Resident R1, and received documents pertinent to the investigation. LPA received copies of pertinent documents including staff roster, client roster, residents Pre-Appraisal, Needs and Service Plan, Dietary Orders, Physicians Report, Doctors Orders, Medication Administration Record, staff notes, hospital discharge papers, shower schedule and menu.
On a visit conducted on 10/20/23, LPA interviewed Staff S2 and S3, and interviewed Residents R2-R5.

The investigation revealed the following:
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
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 13
Control Number 11-AS-20230626162504
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 II
FACILITY NUMBER: 198602152
VISIT DATE: 05/06/2024
NARRATIVE
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Allegation: Staff did not provide resident with special diet according to resident’s health care needs.

The allegation alleges that some residents have a special diet and the meals served are high in fat, sodium, and carbohydrates.

During interviews with staff (S1-S3), were asked if residents special diet orders are followed, three (3) out of three (3) stated they follow resident’s special diets from their physicians. Interviews with Residents (R1-R5) three (3) out of five (5) stated they do not have any dietary restrictions. Residents R2 and R5 stated they have dietary restrictions and that they are served things they should not be eating due to their health conditions. R5 stated they are served sandwiches on white bread with high sodium meats. R1 stated they are given carbohydrates LPA reviewed physician’s orders for R1, R2, and R5, and found they required a special diet of low sodium, low carbohydrates, and low sugar. LPA reviewed the sample menu and observed many of the item are high in carbohydrates.

Allegation: Staff did not dispense medications as prescribed

The allegation alleges that medications are not properly dispensed even after doctors and nurses have conferenced with onsite caregiver.

During record review of the Resident’s medication administration record (MAR), LPA observed the MAR did not have accurate documentation of medications administered to residents. Additionally, LPA observed R1 has two (2) PRN

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 13
Control Number 11-AS-20230626162504
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 II
FACILITY NUMBER: 198602152
VISIT DATE: 05/06/2024
NARRATIVE
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medications that are “take as needed” and there is no MAR indicating if or when resident took the medications. During record review, LPA observed on R1’s Physician’s Report they cannot manage their own medications. During interviews with Staff S1-S3, were asked if residents are given their medications as prescribed, three (3) out of three (3) stated residents medications are given as prescribed. During interviews with Residents R1-R5, were asked if they receive their medications as prescribed, four (4) out of five (5) stated they receive their medications as prescribed, and R3 stated they handle their own medications.

During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D.

An exit interview was conducted with Staff, Rey Malit, and a copy of this report was provided.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 13
Control Number 11-AS-20230626162504
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 II
FACILITY NUMBER: 198602152
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/20/2024
Section Cited
CCR
87555
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87555 General Food Service Requirements (b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident’s physician as a medical necessity shall be provided.
This was not met based on:
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Licensee aggrees to review Physicians Reports of residents, train staff on resident special diets. Have staff sign that they have been trained on residents special diet and fax to 424-544-1017 att LPA Gibbs by POC date.
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LPA reviewed physician’s orders for R1, R2, and R5, and found they required a special diet of low sodium, low carbohydrates, and low sugar and during interviews with R2 and R5 stated they are served item that do not meet the modified diet prescribed by physician. This poses a health and safety risk to residents in care.
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Type B
05/20/2024
Section Cited
CCR
87465
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87465Incidental 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 for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) a record of each dose is maintained in the resident’s record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident’s response.
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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 424-544-1016 att Gibbs by POC date.
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This was not met based on: Record review of Resident R1s Physicians report and Centrally stored medications has 2 PNR medications and there is no documentation of R1 receiving thier PRN. This poses a 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.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
06/26/2023 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 11-AS-20230626162504

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: 2DATE:
05/06/2024
UNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:Rey MalitTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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2
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Staff inappropriately touched resident
Staff financially abused resident
Staff falsified resident's medical documentation
Staff are not bathing resident according to doctor’s orders
Direct care staff are not being informed of resident’s needs
Staff were not able to communicate due to language barrier
Staff did not provide adequate activities for resident
Facility does not respond to communications from resident’s authorized representative
Staff did not notice a change in resident’s condition
INVESTIGATION FINDINGS:
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On 05/06/24, Licensing Program Analyst (LPA), Wendy Gibbs conducted a subsequent visit to the facility listed above to deliver findings for a complaint. LPA met with care staff Rey Malit, and the purpose of today’s visit was explained. During today’s visit there were two residents present.
During today’s visit, LPA toured the facility and reviewed the report with staff.
On a previous visit conducted on 06/27/23, LPA toured the facility, interviewed staff S1, interviewed Resident R1, and received documents pertinent to the investigation. LPA received copies of pertinent documents including staff roster, client roster, residents Pre-Appraisal, Needs and Service Plan, Dietary Orders, Physicians Report, Doctors Orders, Medication Administration Record, staff notes, hospital discharge papers, shower schedule and menu.
On a visit conducted on 10/20/23, LPA interviewed Staff S2 and S3, and interviewed Residents R2-R5.

The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 13
Control Number 11-AS-20230626162504
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 II
FACILITY NUMBER: 198602152
VISIT DATE: 05/06/2024
NARRATIVE
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Allegation: Staff inappropriately touched resident.
The allegation alleges that a staff might have touched a resident inappropriately.
During interviews with Staff (S1- S3), were asked if they or another staff have touched a resident inappropriately, three (3) out of three (3) stated they have not touched any resident inappropriately, nor have they heard of resident being touched inappropriately. Additionally, Staff stated the only time they touch a resident is to provide care and if they are helping a resident with incontinent care or bathing, they ensure there is second staff in the room to assist. During interviews with Residents (R1-R5), were asked if staff have touched them inappropriately, five (5) out of five (5) residents stated they have not been touched inappropriately by staff. Residents have no concerns regarding their safety with staff. LPA reviewed past SIRs and past complaints and did not find any incidents regarding touching a resident inappropriately.

Allegation: Staff financially abused resident.


The allegation alleges that the reporting party has witnessed other POA’s for patients at the facility accuse staff of financial theft.
During interviews with Staff (S1- S3), they were asked if they or any staff have taken resident’s money, three (3) out of three (3) stated they have not taken money from any residents. Staff S1 stated when going shopping they have taken requests for specific items from residents, and they have given money for those items with a receipt provided. S2 stated there was an allegation of staff taking a resident’s money where the police and a social worker have been involved and that staff is no longer working here. During interviews with Residents (R1-R5), they were asked if
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 13
Control Number 11-AS-20230626162504
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 II
FACILITY NUMBER: 198602152
VISIT DATE: 05/06/2024
NARRATIVE
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staff has asked them for or taken money from them, five (5) out of five (5) stated they have not been asked for money by staff. Resident R3 stated they have asked S1 to pick up specific items while at the store and a receipt is provided so they know how much to pay. During file review LPA found that the facility does not handle any of the resident’s finances, either the resident or their representative handles their finances.

Allegation: Staff falsified resident’s medical documentation.

The allegation alleges that the caregiver has lied about resident’s results and does not document readings unless there is a complaint, and then makes numbers up.

During the visit LPA observed R1 test their sugar with staff S1 next to them recording the numbers on a log sheet. During interviews with staff S1 stated they will get everything ready for R1 to test their sugar and they record the readings. During interviews with Resident R1 stated they test their sugar daily and that staff S1 is there to record the numbers. During document review, LPA observed that the resident’s levels are tested daily, and the log is kept on a corkboard in the dining room. During interviews with staff S1-S3, were asked if they have or know of a staff who have falsified records, three (3) out of three (3) stated they have not falsified records and do not have knowledge of staff falsifying records. During interviews with Residents (R1-R5), they were asked if they have any knowledge of staff falsifying records, five out of five stated they have no knowledge of staff falsifying records.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 13
Control Number 11-AS-20230626162504
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 II
FACILITY NUMBER: 198602152
VISIT DATE: 05/06/2024
NARRATIVE
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Allegation: Staff are not bathing resident according to doctor’s orders

The allegation alleges that the staff does not do any hygienic care (showering, toileting) and leaves clients on their own to attend to themselves.

During interviews with Staff (S1- S3) three out of three stated the residents are bathed regularly. Interviews with Residents (R1-R5) five out of five stated they are assisted with bathing regularly. R1 and R4 stated they receive help when they shower twice a week. R3 and R5 stated they are assisted daily with showering. R2 stated they do not require assistance with the shower, and they shower daily. During file review, LPA did not see any orders from the resident’s physician regarding showering, and how often they should shower.

Allegation: Direct care staff are not being informed of residents’ needs.

The allegation alleges that relief staff are not notified of client’s care and medical conditions.

During interviews with staff S1-S3, were asked if they are informed of resident’s needs, three (3) out of three (3) stated that when there are changes in a resident’s care they are informed by the family, hospice nurse, new doctor’s orders, other staff, or the residents of these changes. During interviews with Residents R1-R5, were asked if their needs are met, five (5) out of five (5) stated their needs are met. During file review, LPA observed staff receive training regarding care for residents conducted on 02/21/23.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
LIC9099 (FAS) - (06/04)
Page: 8 of 13
Control Number 11-AS-20230626162504
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 II
FACILITY NUMBER: 198602152
VISIT DATE: 05/06/2024
NARRATIVE
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Allegation: Staff are not able to communicate due to a language barrier.

The allegation alleges that staff are brought from another country who do not speak the language.

During facility visits, LPA did not have any issues communicating with the staff. During interviews with Staff (S1-S3), were asked if they have any issues communicating with residents, three (3) out of three (3) stated they have no issues communicating with residents. During interviews with Residents R1-R5, were asked if they have any issues communicating their needs to staff, five (5) out of five (5) stated they have not issues communicating with staff.

Allegation: Staff did not provide adequate activities for residents

The allegation alleges that they do not have or offer activities to residents.

During interviews with staff (S1-S3), were asked if residents are provided with activities, three (3) out of three (3) stated activities are provided for residents, but not all the residents want to participate. S2 stated if residents don’t want to participate, they try to find something they want to do, one resident likes to listen to music, another dance, and another likes to talk politics and about what is happening in the world. During interviews with Residents (R1-R5), were asked if activities are provided, five (5) out of five (5) stated there are minimal activities provided. Residents (R3-R5) stated they would rather do their own thing. During facility inspection, LPA observed games, activities, and karaoke available for residents. Additionally, LPA observed three residents singing with staff.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
LIC9099 (FAS) - (06/04)
Page: 9 of 13
Control Number 11-AS-20230626162504
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 II
FACILITY NUMBER: 198602152
VISIT DATE: 05/06/2024
NARRATIVE
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Allegation: Facility staff does not respond to communications from resident’s authorized representative.
The allegation alleges that a resident’s representative has sent many text messages to the supervisor and caregiver about their concerns, and they were met with hostility in text messages from the caregiver.
During interviews with Staff S1-S3, they were asked if they communicate and respond to resident’s authorized representatives, three (3) out of three (3) stated they communicate and respond to resident’s representatives. During interviews with Residents R1-R5, were asked if staff respond to their authorized representatives inquires, three (3) out of five (5) stated they believe staff respond to their authorized representatives inquires. Residents R3 and R4 stated they are self responsible.

Allegation: Staff did not notice a change in residents’ condition.


The allegation alleges that a resident called another resident’s POA to inform them their resident was felling confused.
During interviews with Staff (S1-S3), were asked if they watch residents for a change of condition and report it to their authorized representative, three (3) out of three (3) stated they watch for changes in condition and if they observe any, they contact the residents responsible party and the Physician and if necessary, call 911. During interviews with residents R1-R5, were asked if they received medical assistance when needed, five (5) out of five (5) stated they receive medical assistance when needed. During record review, LPA reviewed resident’s file folders and observed documents from doctor and hospital visits.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
LIC9099 (FAS) - (06/04)
Page: 10 of 13
Control Number 11-AS-20230626162504
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 II
FACILITY NUMBER: 198602152
VISIT DATE: 05/06/2024
NARRATIVE
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Unsubstantiated During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

An exit interview was conducted with Staff, Rey Malit, and a copy of this report was provided.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
LIC9099 (FAS) - (06/04)
Page: 11 of 13
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 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
06/26/2023 and conducted by Evaluator Wendy Gibbs
COMPLAINT CONTROL NUMBER: 11-AS-20230626162504

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: 2DATE:
05/06/2024
UNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:Rey MalitTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Staff neglect has resulted in resident developing multiple infections
INVESTIGATION FINDINGS:
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On 05/06/24, Licensing Program Analyst (LPA), Wendy Gibbs conducted a subsequent visit to the facility listed above to deliver findings for a complaint. LPA met with care staff Rey Malit, and the purpose of today’s visit was explained. During today’s visit there were two residents present.
During today’s visit, LPA toured the facility and reviewed the report with staff.
On a previous visit conducted on 06/27/23, toured the facility, interviewed staff S1, interviewed Resident R1, and received documents pertinent to the investigation. LPA received copies of pertinent documents including staff roster, client roster, residents Pre-Appraisal, Needs and Service Plan, Dietary Orders, Physicians Report, Doctors Orders, Medication Administration Record, staff notes, hospital discharge papers, shower schedule and menu.
On a visit conducted on 10/20/23, LPA interviewed Staff S2 and S3, and interviewed Residents R2-R5.

The investigation revealed the following:
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 12 of 13
Control Number 11-AS-20230626162504
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 II
FACILITY NUMBER: 198602152
VISIT DATE: 05/06/2024
NARRATIVE
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Allegation: Staff neglect has resulted in resident developing multiple infections.

The allegation alleges that a resident has been in and out of the hospital due to infections for UTIs and bacterial infections.

During record review, LPA observed hospital documents regarding R1 experiencing Urinary Retention causing UTIs. During interviews with Staff S1-S3, were asked if residents care needs are being neglected causing infections, three (3) out of three (3) stated the residents are not being neglected and their care needs are being met. During interviews with Residents (R1-R5), were asked if their care needs are being neglected resulting in infections, five (5) out of five (5) stated their care needs are being met.

Unsubstantiated During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.



An exit interview was conducted with Staff, Rey Malit, and a copy of this report was provided.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Wendy Gibbs
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
LIC9099 (FAS) - (06/04)
Page: 13 of 13