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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602162
Report Date: 08/08/2024
Date Signed: 08/22/2024 12:55:18 PM

Document Has Been Signed on 08/22/2024 12:55 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: 3DATE:
08/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:24 AM
MET WITH:ADMINISTRATOR EVANGELINE AGATEPTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 08/08/2024 at 11:30 AM, Licensing Program Analyst LPA) Jose Calderon conducted an unannounced annual inspection visit at the Santa Fe Home Care III Facility. LPA Calderon was allowed entry into the facility by Administrator Evangeline Agatep. Administrator Evangeline Agatep asked infection control questions and took LPA Calderon temperature prior to entrance into the facility. The facility is licensed for six (6) non-ambulatory elderly adults ages 60 and over of which one (1) may be bedridden and have an approved hospice waiver for four (4). Currently, there are three (3) residents residing in the facility, between the age of 18 to 59 with cognitive issues.

LPA Calderon explained to Administrator Evangeline Agatep, the purpose of the one-year Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: Three (3) client service records, three (3) client medication records (MAR), three (3) staff records, and inspected the inside facility and outside grounds. LPA Calderon interviewed three (3) clients and three (3) staff members for visit. The facilities’ last fire drill was conducted on 08/05/2024. The one-story residential home consists of four (4) client bedrooms, two (2) client bathrooms, living room, dining room, kitchen, staff room, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A two-day supply perishable and seven-day supply of non-perishable foods are present in the facility. Emergency Water Storage is in the garage and kitchen area.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE: DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/16/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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: 08/08/2024
NARRATIVE
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LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of client’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 110 degrees Fahrenheit, and bathroom #2 hot water temperature properly measured at 111 degrees Fahrenheit. Kitchen hot water temperature properly measured at 112 degrees Fahrenheit. Facility (2) Carbon Monoxide and (6) Smoke Detectors are batterie run and connected were tested and are working properly. The facility has no Fire Extinguishers in the facility. Fire Extinguishers were ordered on 8/5/2024. All exit doors in the facility have alarm systems. The facility has a working landline telephone. All toxins and knifes are locked/secured and inaccessible to clients. Medications are centrally stored and in a locked storage cabinet. Facility one (1) first aid kit is fully stocked with manuals was checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to clients. Three (3) client files were reviewed and found to be complete. LPA Calderon reviewed three (3) resident medications (MAR) and they were all found to be administered according to doctor's orders. Three (3) staff files were checked and have the required documents. LPA Calderon noted the Administrator Evangeline Agatep Certification # 6021587740 expiration date of 11/08/2024 was valid at time of inspection. The facility does not handle client's money/cash resources and a Surety bond is not needed. Commercial General Liability Policy #RN70327041 policy period from 08/18/2023 to 08/18/2024 underwritten by Richmond National Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. Administrator Evangeline Agatep to email LPA Calderon a full copy of the commercial insurance policy including all endorsements no later than 08/23/2024. All the required documents are posted in the facility in a clearly visible area.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
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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: 08/08/2024
NARRATIVE
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During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and clients, sanitizing stations (Located in common areas and restrooms). LPA observed staff and clients were NOT wearing face coverings. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE).

LPA Calderon advised the Administrator Evangeline Agatep to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did observe 2 deficiencie therefore TWO citations were issued at this time. Annual Licensing Fee is CURRENT $495.00 is owed on 08/25/2024, PIN 217993. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Evangeline Agatep.
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Jose Calderon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/22/2024 12:55 PM - It Cannot Be Edited


Created By: Jose Calderon On 08/22/2024 at 10:55 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: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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MOVE CLEANING SUPPLIES AND LOCK UP
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Ulysses Coronel
LICENSING EVALUATOR NAME:Jose Calderon
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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Document Has Been Signed on 08/22/2024 12:55 PM - It Cannot Be Edited


Created By: Jose Calderon On 08/22/2024 at 10:56 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: 08/08/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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FACILITY WILL REPAIR SCREEN DOOR
Type B
Section Cited
CCR
87303(e)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/20/2024
Plan of Correction
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FACILITY WILL REPAIR BATHROOM FACUET
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:Ulysses Coronel
LICENSING EVALUATOR NAME:Jose Calderon
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


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