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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 06:09:32 PM

Document Has Been Signed on 08/22/2024 06:09 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 - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:28 PM
MET WITH:Evangeline AgatepTIME VISIT/
INSPECTION COMPLETED:
02:29 PM
NARRATIVE
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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.

LPA reviewed resident's service records and identified Resident #1 (R1) who is under hospice care is unable to self-care requires night supervision. (R1's) Physician's Report LIC 602-A indicated (R1) requires continuous bed care as (R1) is bladder and bowel impairment with dementia.

According to Personnel Report LIC 500 night supervision is on-call basis. There is no regular staff assigned to night supervision shift after 11:00 pm.

Based on observations, interviews, and record reviews, the preponderance of evidence standard has been met with California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D.

Exit interview was conducted with Evangeline Agatap, and a hard copy of the report along with appeal rights.

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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Document Has Been Signed on 08/22/2024 06:09 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 08/22/2024 at 01:48 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: 08/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2024
Section Cited
CCR
87705(4)(A)

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87705 Care of Persons with Dementia
(4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision.
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Licensee will adhere to Title 22 87705 Regulations and ensure that at least one staff for NOC shift. Plan of correction must be sent to LPA by POC date via email: ernand.dabuet@dss.ca.gov
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This requirement is not met as evidence by:
Based on interviews and record reviews, licensee did not have night supervision for dementia resident (R1). No staff on duty after 11pm. This violation poses a potential health and safety risk to 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.
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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