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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602162
Report Date: 11/16/2021
Date Signed: 11/17/2021 04:50:31 PM

Document Has Been Signed on 11/17/2021 04:50 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
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: 4DATE:
11/16/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:03 PM
MET WITH:Virginia AsisTIME COMPLETED:
06:34 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ulysses Coronel conducted an unannounced Case Mangement - Deficiencies visit to document deficiencies observed during the course of the complaint investigation on a complaint with complaint control number 11-AS-20211112163455.

California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC809D.

An exit interview was conducted and plans of correction were developed. A copy of this report and appeals rights were provided.
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ulysses Coronel
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2021
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 11/17/2021 04:50 PM - It Cannot Be Edited


Created By: Ulysses Coronel On 11/16/2021 at 05:26 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/30/2021
Section Cited
CCR
87303(a)

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87303(a) Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met as evidenced by:
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The administrator agreed to review Title 22 Regulation 87303(a) Maintenance and Operation. And will crate a plan to ensure that the facility will be in good repair at all times. Proof of correction to be submitted by POC due date.
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Based on LPA observation the licensee failed to ensure that the screen doors by the kitchen and room number 4 were in good repair which poses a potential health and safety risk to clients in care.
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Type B
11/30/2021
Section Cited
CCR87211(a)(1)(D)

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87211(a)(1)Reporting Requirements. Each licensee shall furnish... the following: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days...below. This... case. Any incident which threatens the welfare, safety or health of any...resident.
This requirement was not met as evidenced by:
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The administrator agreed to review Title 22 Regulation 87211(a)(1)Reporting Requirements. And will crate a plan to ensure that incident reports will be submitted to CCL in a timely manner. Proof of correction to be submitted by POC due date.
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Based on interviews and record reviews the licensee failed to ensure that written reports of R2's agressive behaviors towards residents R1 and R3 were submitted to CCL within 7 days of the incidents which 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:Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2021


LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 11/17/2021 04:50 PM - It Cannot Be Edited


Created By: Ulysses Coronel On 11/16/2021 at 05:56 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
, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/23/2021
Section Cited
CCR
87405

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87405(d)(1) Administrator - Qualifications and Duties. The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If ...apply. Knowledge of the requirements for providing care and supervision appropriate to the residents.
This requirement was not met as evidenced by:
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The administrator agreed to review Title 22 Regulation 87405(d)(1) Administrator - Qualifications and Duties. And will crate a plan to obtain better knowledge of the requirements for providing care and supervision appropriate to the residents. Proof of correction to be submitted by POC due date.
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Based on LPA observations and inteviews conducted the licensee failed to ensure that administrator Virginia Asis had the knowledge of the requirements for Maintenace & Operation, Reporting Requirements and Observation of clients which poses a potential health and safety risk to clients 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:Ulysses Coronel
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2021


LIC809 (FAS) - (06/04)
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