198602152-9-23-2022-11-AS-LMOA-CJK6P2-20220923205821

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602152
Report Date: 09/23/2022
Date Signed: 09/23/2022 08:58:33 PM

Document Has Been Signed on 09/23/2022 08:58 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME:	SANTA FE HOME CARE II		FACILITY NUMBER:	198602152
ADMINISTRATOR:	ASIS, VIRGINIA		FACILITY TYPE:	740
ADDRESS:	2255 SANTA FE AVENUE		TELEPHONE:	(424) 558-8285
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90501
CAPACITY: 6		CENSUS: 4	DATE:	09/23/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:25 PM
MET WITH:	LUCY DEZELL / VIRGINIA ASIS		TIME COMPLETED:	04:30 PM

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On 09/23/2022 at 12:25 pm, Licensing Program Analysts (LPAs) Lourdes Montoya and Wendy Gibbs conducted an unannounced Required – 1 Year Inspection. LPA Montoya called the Administrator Virginia Asis (S1) who confirmed the facility is free of Covid-19 infection. LPAs met with House Manager Lucy Dezell (S2) and Volunteer caregiver Patricia Ozekie (S3). LPA explained the purpose of the visit. Administrator Asis arrived later and joined the visit. There were four (4) residents present in the facility during the inspection. Caregiver Rey Malit (S4) arrived to relieve Volunteer Ozekie. At around 1:44 pm, the Administrator and Staff 1 left the facility.

Facility is licensed licensed to serve clients age 60 and over, six (6) non-ambulatory. Approved Hospice Waiver for six (6) residents. The Annual Licensing Fees are current.

The facility is a single story structure located in a residential neighborhood. It consists of the following: three (3) bedrooms, 2 bathrooms, living room, kitchen, dining room, family room, garage and a shaded area.

LPA Montoya toured and inside and outside grounds of the facility with Staff Dezell. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured at 124.4 and 124.0 degree Fahrenheit in resident bathrooms. A comfortable temperature was maintained in the facility.

LPA observed the facility was found to be appropriately furnished at the time of visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food supplies. The facility has (1) fire extinguisher that was charged, smoke detectors, and carbon monoxide were operable. One fire extinguisher located in the laundry room mounted on the wall was last serviced on 2/15/2018. The facility conducted a Fire/Safety Drill on 7/26/2022. A working telephone 424-558-8285 remains available.

Evaluation Report Continues on LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SANTA FE HOME CARE II	FACILITY NUMBER: 198602152
	VISIT DATE: 09/23/2022

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During the visit, LPA observed the facility's infection control practices. LPA observed a sanitizing station in common areas. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved Mitigation Plan Report on file with CCLD.

LPA Montoya and LPA Gibbs observed the following deficiencies.
1. Volunteer staff (S3) – No fingerprint /background clearance and not Associated to the facility.
2. Water temperature in the common bathroom is 124.4 degree Fahrenheit and the water temperature in bedroom # 3 is 124.00 degree Fahrenheit.
3. Fireplace in the family room is not properly screened.
4. Yellow basin with water was observed in the backyard.
5. Three stove burners not operable.
6. Sliding door screen is torn; sliding door and screen door are not in good repair.
7. Doorbell is broken off the wall.
8. Administrator made false statements about volunteer staff’s (S3) start date of work and worked days.
9. PUB 475 is on 8”x12” paper.
10. No Covid-19 screening form; No screening records
11. No handwash poster in both bathrooms.
12. Plastic container of frozen fries is not properly sealed.
13. Medication is dispensed to another container one week prior to administration per Staff 2.
14. Resident #1 has no Physician’s Report on file.
15. Former residents’ wheelchairs are stored in the garage.
16. Expired food per Resident #2.
17. Auditory devices in the main door and sliding door in the kitchen are not operable.
18. A fire extinguisher in the laundry was last serviced on 2/15/2018.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the above deficiencies. Due to time constraints, the annual inspection will be continued at a later date and citations will be issued for the above deficiencies.

Administrator and the House Manager were no longer present in the facility during the exit interview.

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

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022

LIC809 (FAS) - (06/04)

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