198602152-12-13-2023-11-AS-WGIS-CYH2KV-20231213162834

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602152
Report Date: 10/20/2023
Date Signed: 12/13/2023 04:28:50 PM

Document Has Been Signed on 12/13/2023 04:28 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
EL SEGUNDO ASC, 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:	10/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:37 PM
MET WITH:	James Okeuhie		TIME COMPLETED:	04:45 PM

NARRATIVE

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On 10/20/23, Licensing Program Analyst (LPA), Wendy Gibbs conducted an unannounced annual visit using the full CAREs tool. LPA met with Caregiver, James Okeuhie, and explained the purpose of today’s visit. The facility is licensed to serve clients aged 60 and over, six non-ambulatory. They have an approved Hospice Waiver for six residents. There are currently 4 residents residing at the facility.

Physical Plant/Structure 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 toured the inside and outside grounds of the facility with staff. All walkways on the side of the facility were clean, clear, and free of obstruction, debris, and hazards. There were no bodies of water observed.

Bedrooms All bedrooms were inspected. All rooms have the required furniture including a bed(s), dresser(s), nightstand(s), chair(s), and storage space for residents’ personal belongings. All beds were observed to have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. LPA observed an ample supply of bed linens in a hall cupboard that were in good repair. All bedrooms were observed to have ample lighting.

Bathrooms LPA inspected all bathrooms. Bathrooms were found to be within Title 22 regulations and were clean and operational. All bathrooms had secured handrails, nonskid mats, and a shower chair. LPA observed an ample supply of hygiene products and towels stored in a cupboard in the hall. The water temperature measured 118.3 and 119.2-degrees Fahrenheit.

Kitchen LPA inspected the kitchen and found it to be clean and sanitary. All appliances were tested and are in good working condition. LPA observed an ample supply of cutleries, pots, and pans in good repair. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. All food was properly labeled and stored. The water temperature measured 119.8-degrees Fahrenheit. All sharps were observed in a locked drawer in the kitchen and are inaccessible to residents. LPA observed all cleaning products secured in a locked cabinet under the sink and are inaccessible to residents.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SANTA FE HOME CARE II	FACILITY NUMBER: 198602152
	VISIT DATE: 10/20/2023

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Common Rooms LPA inspected all common rooms. LPA observed two couches and activities in the family room for resident use. The living room has 5 recliners for residents. LPA observed a screened fireplace that is inaccessible to residents. The dining room has a large table and chairs to accommodate all residents.

LPA will return to complete file review and medication review.

An exit interview was conducted with Caregiver, James Okeuhie, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/13/2023 04:28 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above, it was observed during file review that R1 does not have a Physicians Report on file, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/27/2023
	Plan of Correction
1 2 3 4	Administrator will submitt a medical assessment (Physician's Report) for Resident R1 to LPA by 12/27/23.

Type B

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above, it was observed during file review that R1 does not have a recent TB test on file, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 12/27/2023
	Plan of Correction
1 2 3 4	Administrator will submitt a tuberculosis test for Resident R1 LPA by 12/26/23.

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	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 12/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023

LIC809 (FAS) - (06/04)

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