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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602162
Report Date: 04/28/2022
Date Signed: 04/28/2022 08:20:01 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
04/20/2022 and conducted by Evaluator Don Senaha
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20220420104244
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:
04/28/2022
UNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:House Manager Richard Librando/Administrator Virginia AsisTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Resident was hit while in care.
INVESTIGATION FINDINGS:
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On 04/28/2022 Licensing Program Analyst (LPA) Don Senaha initiated a complaint investigation for the allegation listed above. Today’s complaint investigation was conducted with House Manager Richard Librando and later joined by Administrator Virginia Asis.

The investigations consisted of the following: LPA requested resident roster, staff roster and other service documents on 04/28/2022. LPA interviewed residents (R1-R4), staff (S1-S3) and witness (W2-W3).

A plant inspection of the facility was conducted on 04/28/2022. Deficiencies were cited on Case Mangement conducted on 04/28/2022.

Investigation revealed:
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
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-20220420104244
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: 04/28/2022
NARRATIVE
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Allegation: Resident was hit while in care.

It is alleged that resident was hit while in care.

Resident (R1) stated he was hit with a cane last week by resident (R5) while in his bed on the head. Resident (R1) stated he was struck with the cane 4 or 5 times prior to staff (S1) intervening last week. Resident (R1) stated this was not the first time resident (R5) has struck resident (R1). Resident (R5) struck him the first time with his cane and he was injured with a bump on his head prior to staff (S1) intervened a couple weeks ago. Staff (S1) stated he witnessed resident (R5) hitting resident (R1) with his cane both times. The first incident staff (S1) did not report it but stated resident (R1) did have a bump on his head. The second incident staff (S1) stated after he intervened, he called the Police Department who took resident (R5) into custody with them. Witness (W2) confirmed resident (R5) in still being held with the authorities. Staff (S1) did let corporate office know witness (W1) about the incident.

Based on LPA’s interviews conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 11-AS-20220420104244
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: 04/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/06/2022
Section Cited
CCR
87468.1(a)(3)
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87468.1 Personal Rights of Residents in All Facilities. (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse...or interfering with daily living functions such as eating, sleeping, or elimination.
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The administrator agreed to review Title 22 Regulation 87468.1 Personal Rights of Residents in All Facilities and signed that she understands this section of Title 22 regulations. Proof of correction to be submitted by POC due date of 05/06/2022.
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Based on interviews and record reviews the licensee failed to ensure resident (R1) personal rights by allowing resident (R5) to use aggressive behaviors towards residents R1 which poses a potential 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: Don Senaha
LICENSING EVALUATOR SIGNATURE:

DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/28/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3