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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602152
Report Date: 09/27/2022
Date Signed: 09/27/2022 03:46:42 PM

Document Has Been Signed on 09/27/2022 03:46 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 IIFACILITY NUMBER:
198602152
ADMINISTRATOR:ASIS, VIRGINIAFACILITY TYPE:
740
ADDRESS:2255 SANTA FE AVENUETELEPHONE:
(424) 558-8285
CITY:TORRANCESTATE: CAZIP CODE:
90501
CAPACITY: 6CENSUS: 4DATE:
09/27/2022
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:21 AM
MET WITH:LUCY DEZELL / VIRGINIA ASISTIME COMPLETED:
03:30 PM
NARRATIVE
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On 09/27/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted a continuation of an annual inspection. LPA Montoya called the Administrator Virginia Asis (S1) who confirmed the facility is free of Covid-19 infection. LPA 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 three (3) residents present in the facility during the inspection.

Technical violations and technical assistance were issued to licensee.

The following deficiencies were observed on 9/23/22 (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. Appeal rights and a copy of this report was provided to Administrator Virginia Asis.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
Document Has Been Signed on 09/27/2022 03:46 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 09/27/2022 at 10:19 AM
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
, 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: 09/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observations, the licensee did not comply with the section cited above. The water temperature in the common bathroom is 124.4 degree Fahrenheit and the water temperature in bedroom # 3 is 124.00 degree Fahrenheit. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2022
Plan of Correction
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Administrator shall ensure the water temperature in resident bathrooms is in compliance. Administrator shall adjust the water temperature to not less than 105 to and not more than 120 degree Fahrenheit. POC shall be submitted to CCLD via email to Lourdes.montoya@dss.ca.gov
Type A
Section Cited
CCR
87355(e)(1)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering 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:
Deficient Practice Statement
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Based on LPA Montoya’s interview with the Administrator (S1) on 9/23/22, S3 started working on 9/23/22 without a background clearance. LPA Montoya and LPA Gibb observed S3 is working in the facility in blue scrub uniform. Based on review of S3’s timesheet, she began working on 9/14/2022 to date. On 9/27/22, LPA returned to the facility and observed S3 is working again without background clearance. The administrator failed to ensure S3 obtained a California background clearance prior to working or volunteering. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2022
Plan of Correction
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LPA Montoya and LPA Gibb observed S3 left the facility around 1:44 pm and was relieved by S4. On 9/27/22, S3 left the faciity at around 2:30 pm and was relieved by S4. This deficiency has been corrected.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2022


LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/27/2022 03:46 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 09/27/2022 at 10:21 AM
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
, 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: 09/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(7)
Personal Accommodations and Services
(7) Fireplaces and open-faced heaters shall be adequately screened.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. The fireplace in the family room is not properly screened which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2022
Plan of Correction
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Administrator shall ensure the fireplace is properly screened. POC shall be submitted to CCLD via email to Lourdes.montoya@dss.ca.gov by the POC due date.
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. Resident #1 has no Physician’s Report on file. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2022
Plan of Correction
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Administrator shall ensure Resident #1 has a current Physician's Report (medical assessment) on file readily available for inspection by CCLD. POC shall be submitted to CCLD via email to Lourdes.montoya@dss.ca.gov by the POC due date.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2022


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 09/27/2022 03:46 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 09/27/2022 at 10:21 AM
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
, 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: 09/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. Medication is dispensed to another container one week prior to administration per Staff 2. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2022
Plan of Correction
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Administrator shall ensure resident medications that are centrally stored shall be stored in its original container and shall not be transferred between containers. Administrator shall read Section 87465 and shall self-certify understanding of the regulations and shall commit to comply. Administrator shall conduct an in-service training to all staff and send a proof of the completed proof. POC shall be submitted to CCLD via email to Lourdes.montoya@dss.ca.gov by the POC due date.
Type B
Section Cited
CCR
87303(a)
(a) The facility shall be clean, safe, and sanitary andn in good repair at all times. Maintenance shall include provision of maintenance srevices and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA Montoya and LPA Gibb observed three stove burners are not operable; the sliding door in the kitchen and the screen door are not in good repair; doorbell is broken off the wall; a missing kitchen cabinet; a fire extinguisher mounted in the laundry room was last serviced on 2/15/2018. This poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/10/2022
Plan of Correction
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Administrator shall ensure all broken items mentioned in deficient practice statement are repaired by the POC due date. POC shalle be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date, 10/10/2022.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2022


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 09/27/2022 03:46 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 09/27/2022 at 10:56 AM
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
, 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: 09/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87405(d)(2)
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (2) Knowledge of and ability to conform to the applicable laws, rules and regulations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA Montoya’s interview with the Administrator (S1), S3 started working on 9/23/22 without a background clearance. LPA Montoya and LPA Gibss observed S3 is in the facility in blue scrub uniform. Based on review of S3’s timesheet, S3 worked on 9/14/22-9/18/22 and based on interview with R1 and R2, S3 continued to work on 9/19/22, 9/20/22 and 9/23/22. The administrator failed to ensure S3 obtained a California background clearance prior to working or volunteering which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2022
Plan of Correction
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Administrator shall review Section 87405 of Title 22 and shall self-certify understanding of this regulation and shall commit to comply. Administrator shall submit a self-certification letter to CCLD via email to Lourdes.montoya@dss.ca.gov
Type A
Section Cited
CCR
87405(d)(5)
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply. (5) Good character and a continuing reputation of personal integrity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, record review, the licensee did not comply with the section cited above. The administrator (S1) stated S3 just started working on 9/23/2022 when asked by LPA Montoya. Based on LPA Montoya’s interview with two residents (R1 and R2), and review of S3’s timesheet, S3 began working at the facility on 9/14/2022 and continued to work until LPA's visit day. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/28/2022
Plan of Correction
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Administrator shall not make false statements to CCLD and shall always display good character and a continuing reputation of personal integrity. Administrator shall review Section 87405 of Title 22 and shall self-certify understanding of the regulation and shall commit to comply. POC shall be submitted to CCLD via email to Lourdes.montoya@dss.ca.gov by the POC due date.
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:Eva M Alvarez
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2022


LIC809 (FAS) - (06/04)
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