<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602162
Report Date: 12/21/2023
Date Signed: 12/22/2023 08:11:16 AM

Document Has Been Signed on 12/22/2023 08:11 AM - 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
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: 3DATE:
12/21/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Rodolfo LozadaTIME COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/21/2023, LPA Lourdes Montoya conducted a case management - deficiency visit at this facility during an unrelated complaint visit. LPA met with Staff Laxuqsha Bailey. LPA explained the purpose of today's visit. Office staff Rodolfo Lozada arrived later and assisted LPA with the visit.

At around 1:55 PM, LPA met with a caregiver (S1) who is not associated with the facility. S1 explained S1 normally works at another facility owned by the same licensee however, today, S1 was called to assist and supervise three residents at Santa Fe Home Care III. S1 stated S1 began working today at 7:20 AM. Based on LPA's interview with Lozada, S1 is fingerprint clear and associated to another facility but not associated to Santa Fe Home Care III. Lozada confirmed S1 commenced working at this facility today.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Civil penalties assessed.

Exit interview conducted. Appeal rights and a copy of this report was provided to Office Staff Rodolfo Lozada.

SUPERVISORS NAME: Stephanie Cifuentes
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 12/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/21/2023
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 2
Document Has Been Signed on 12/22/2023 08:11 AM - It Cannot Be Edited


Created By: Lourdes Montoya On 12/21/2023 at 03:53 PM
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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SANTA FE HOME CARE III
FACILITY NUMBER: 198602162

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/22/2023
Section Cited
CCR
87355(e)(2)

1
2
3
4
5
6
7
(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:

(2) Request a transfer of a criminal record clearance as specified in Section 87355(c)

This requirement was not met as evidence by:
1
2
3
4
5
6
7
Lozada provided LPA with S1's background clearance, Criminal Background Clearance Transfer Request and ID and Personnel Record. This deficiency has been corrected during today's visit.
8
9
10
11
12
13
14
On 12/21/2023 at around 1:55 PM, LPA met with a caregiver (S1) who is not associated with the facility. Based on LPA's interview with Office Staff Lozada, S1 stated is fingerprint clear and associated to another facility but not associated to Santa Fe Home Care III. Lozada confirmed S1 commenced working at this facility today. This poses an immediate risk to health, safety and/or personal rights risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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:Stephanie Cifuentes
LICENSING EVALUATOR NAME:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2023


LIC809 (FAS) - (06/04)
Page: 2 of 2