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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602162
Report Date: 12/22/2023
Date Signed: 12/22/2023 12:24:42 PM


Document Has Been Signed on 12/22/2023 12:24 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:ASIS, VIRGINIAFACILITY TYPE:
740
ADDRESS:23223 PRYOR PLACETELEPHONE:
(310) 989-1941
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY:6CENSUS: 3DATE:
12/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Virginia AsisTIME COMPLETED:
01:00 PM
NARRATIVE
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On 12/22/2023, LPA Lourdes Montoya conducted a case management - deficiency visit at this facility during an unrelated complaint visit. LPA met with Administrator Virginia Asis. LPA explained the purpose of today's visit.

On 12/21/2023 during an investigation of an unrelated complaint, LPA Montoya observed while conducting records review that R1's Safeguard for personal belongings/valuable is not current and complete.

Based on LPA's interviews with S1, S2 and S4, the facility was temporarily closed due to cockroach infestation. S1 and S2 stated the facility was closed on March 2, 2023 for fumigation and was reopened on April 29, 2023. LPA observed the facility failed to report to CCLD the temporary closure of the facility.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations,

Exit interview conducted. Appeal rights and a copy of this report was provided to Administrator Virginia Asis.

SUPERVISOR'S NAME: Stephanie CifuentesTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2023
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 12:24 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2023
Section Cited
CCR
87506(b)(16)

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87506 Resident Records
(b) Each resident’s record shall contain at least the following information:
(16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables.

This requirement was not met as evidenced by:
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Licensee shall ensure all residents have complete and current Safeguards for Personal/Valuable forms. Licensee shall update R1's LIC621 and submit a copy to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date 12/29/23.
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On 12/21/2023 during an investigation of an unrelated complaint, LPA Montoya observed while conducting records review that R1's Safeguard for personal belongings/valuable is not current and complete.
This poses a potential risk to health, safety, and personal rights of residents in care.
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Type B
12/29/2023
Section Cited
ILS87211(a)(1)(D)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.
D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
This requirement was not met as evidenced by:
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Administator shall review the section cited herein and shall self-certify understanding and compliance to this regulation. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
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Based on LPA's interviews with S1, S2 and S4, the facility was temporarily closed due to cockroach infestation. S1 and S2 stated the facility was closed on March 2, 2023 for fumigation and was reopened on April 29, 2023. LPA observed the facility failed to report the temporary closure of the facility. This poses a potential risk to health, safety, and personal rights of 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: Stephanie CifuentesTELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Lourdes MontoyaTELEPHONE: (510) 725-7918
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2023
LIC809 (FAS) - (06/04)
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