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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602162
Report Date: 08/22/2024
Date Signed: 08/22/2024 06:08:58 PM

Document Has Been Signed on 08/22/2024 06:08 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME:SANTA FE HOME CARE IIIFACILITY NUMBER:
198602162
ADMINISTRATOR/
DIRECTOR:		ASIS, VIRGINIAFACILITY TYPE:
740
ADDRESS:23223 PRYOR PLACETELEPHONE:
(310) 989-1941
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY: 6CENSUS: 5DATE:
08/22/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:13 AM
MET WITH:Evangeline AgatepTIME VISIT/
INSPECTION COMPLETED:
01:14 PM
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On 08/22/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a Case Management visit at this facility. LPA met with designated administrator Evangeline Agatep who allowed for the entry in this facility. LPA informed Agatep the purpose of the visit is to conduct a health and safety check.


Investigation revealed the following: LPA conducted a tour of the entire facility. During the inspection, LPA observed the following: (4) bedrooms (2) bathroom, kitchen, living room, den, patio, and garage LPA observed all (5) residents residing at this home requiring assistance with assisted daily living (ADLs) This property address is licensed to Santa Fe Home III #198602162. According to Residential Lease Agreement (dated: 05/24/24), Santa Fe Home III lost control of the property effective 06/04/24. The Residential Lease Agreement contract had Ace Elderly Homes, Inc. under contract effective 06/05/24. Ace Elderly Homes, Inc. submitted an Application for A Community Care Facility LIC 200 on 07/02/24 to Central Applications Bureau, which is still under consideration.

Based on the Department’s observation and interviews conducted, the preponderance of evidence standard has been met, therefore the allegation of “Unlicensed Care is Being Provided" is found to be: "Substantiated".

You are hereby issued a Notice of Operation in Violation of the Law letter. You are to cease operation or submit an application to the CCLD Senior Care Office on or before 09/06/24 or relocate the resident to a licensed assisted living facility. If you fail to: cease operation or relocate the resident a civil penalty will be assessed. Failure to comply will result in civil penalties of $200 per day until a completed application is submitted, operations cease, or written verification from a licensed mental health professional or residents are relocated.
(Evaluation Report continues LIC 809-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SANTA FE HOME CARE III
FACILITY NUMBER: 198602162
VISIT DATE: 08/22/2024
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The operator was given a copy of the “Notice of Operation in Violation of Law" letter.

Deficiency Cited: Health and Safety Code 1569.44.

An exit interview was conducted with Evangeline Agatep, and a copy of the report and appeals rights were provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/22/2024 06:08 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 08/22/2024 at 11:14 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
, 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: 08/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2024
Section Cited
HSC
1569.44(a)

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1569.44(a) Unlicensed residential care facility for the elderly; definition; operation without license prohibited; procedure upon discovery (a) A facility shall be deemed to be an "unlicensed residential care facility for the elderly" and "maintained and operated to provide residential care" if it is unlicensed and not exempt from the licensee, and any one of the following conditions is satisfied:
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Based on interviews conducted and observation the operator is providing unlicensed care to (R1-R5) who require elements of care and supervision. This poses an immediate Health and safety risk to residents in care. The unlicensed operator shall either cease operation of the unlicensed facility or operations ceased or submit an application to the licensing agency within 15 calendar days by 09/06/24. Failure to comply will result in civil penalties of $200 per day until a completed application is submitted,
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This requirement is not met as evidence by:
Based on interviews conducted and observation the operator is providing unlicensed care to R1-R5 who require elements of care and supervision. The facility is not licensed by CCLD. This 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.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2024


LIC809 (FAS) - (06/04)
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