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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602162
Report Date: 11/16/2021
Date Signed: 11/17/2021 04:49:53 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
11/12/2021 and conducted by Evaluator Ulysses Coronel
COMPLAINT CONTROL NUMBER: 11-AS-20211112163455
FACILITY NAME:SANTA FE HOME CARE IIIFACILITY NUMBER:
198602162
ADMINISTRATOR:ASIS, VIRGINIAFACILITY TYPE:
740
ADDRESS:23223 PRYOR PLACETELEPHONE:
(310) 989-1941
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY:6CENSUS: 4DATE:
11/16/2021
UNANNOUNCEDTIME BEGAN:
11:29 AM
MET WITH:Virginia AsisTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Resident was physically attacked by another resident in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Ulysses Coronel conducted an unannounced complaint visit to initiate the investigation on the above-mentioned complaint allegation. LPA met with caregiver Japhet Okechukwu and spoke to administrator Virginia Asis via telephone and the purpose of the visit was explained.

The investigation consisted of the following: During todays visit LPA Coronel conducted a tour of the facility, interviewed the administrator, 2 staff, 4 out of 4 residents and 2 witnesses. LPA also reviewed staff and residents records.

The investigation revealed the following: On 10/29/2021 resident R1 was struck by resident R2 while trying to stop R2 from striking caregiver S1. S1 stated "I was trying to redirect R2 from wandering out of the front door when R2 hit me in the face." R1 stated "The next week my roomate R2 started hitting me while I was in bed, the staff let me stay in their room and took away R2's cane. The next day R2 hit me again while we were in our room. Then R2 was taken by family from here." Witness W2 stated I received around 5 calls regarding R2's agressive behaviors troughout R2's last week at the facility.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
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 3
Control Number 11-AS-20211112163455
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 III
FACILITY NUMBER: 198602162
VISIT DATE: 11/16/2021
NARRATIVE
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Record reviews indicate that R2 was admitted to the facility on 08/27/2021, and was observed having aggressive behavior changes on 10/14/2021, 10/28/2021, 10/31/2021, 11/04/2021, 11/05/2021, 11/06/2021 and 11/07/2021. Regarding the allegation: Resident was physically attacked by another resident in care. Based on LPAs observations and interviews which were conducted and the records that were reviewed, the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

An exit interview was conducted and plans of correction were developed. A copy of this report and appeals rights were provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 11-AS-20211112163455
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 III
FACILITY NUMBER: 198602162
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/23/2021
Section Cited
CCR
87466
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87466 Observation of the Resident . The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When ...any.
This requirement was not met as evidenced by:
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The administrator agreed to review Title 22 regulation 87466 and create a plan to ensure that appropriate assitance will be provided to clients when observed changes in residents reveal unmet needs. Proof of Correction will be submitted by the POC due date.
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This requirement was not met as evidenced by:
Based on observations, interviews and record reviews the licensee failed to ensure that R1 were observed for changes in mental, emotional and social functioning and that appropriate assistance was provided which poses a potential risk to the health and safety of resident 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: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3