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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602162
Report Date: 04/28/2022
Date Signed: 04/28/2022 08:26:26 PM

Document Has Been Signed on 04/28/2022 08:26 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:
04/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:38 PM
MET WITH:House Manager Richard Librando/Administrator Virginia AsisTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Don Senaha 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-20220420104244.

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. Administrator Virginia Asis not present but LPA called her on the phone on 4/28/2022 at 3:58pm and she stated ok for House Manager Richard Librando to sign for reports.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Don Senaha
LICENSING EVALUATOR SIGNATURE: DATE: 04/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/28/2022
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 3
Document Has Been Signed on 04/28/2022 08:26 PM - It Cannot Be Edited


Created By: Don Senaha On 04/28/2022 at 03:24 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: 04/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/06/2022
Section Cited
CCR
87405(d)(1)

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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 signed that she understands the Administrator Qualifications and Duties. Proof of correction to be submitted by POC due date of 05/06/2022.

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Based on LPA observations and interviews conducted the licensee failed to ensure that administrator Virginia Asis had the knowledge of the Reporting Requirements of clients which poses a potential health and safety risk to clients in care.
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Type B
05/06/2022
Section Cited
CCR87307(d)(6)

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87307 Personal Accommodations and Services. (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
This requirement was not met as evidenced by:
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The administrator agreed to review Title 22 Regulation 87307(d)(6) Personal Accommodations and Services and signed that she understands this section of Title 22 regulations. Proof of correction to be submitted by POC due date of 05/06/2022.
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Based on LPA observation conducted the licensee failed to ensure the side of the house is clear of debris for fire safety exit 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:Eva M Alvarez
LICENSING EVALUATOR NAME:Don Senaha
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022


LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 04/28/2022 08:26 PM - It Cannot Be Edited


Created By: Don Senaha On 04/28/2022 at 03:30 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: 04/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/13/2022
Section Cited
CCR
87309(a)(1)

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87309 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. (1) Storage ... other dangerous weapons shall be locked.
This requirement was not met as evidenced by:
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The administrator agreed to review Title 22 Regulation 87309(a)(1) Storage Space and signed that she understands this section of Title 22 regulations. Staff immediately moved the sharps to a locked cabinet. Proof of correction to be submitted by POC due date of 05/06/2022.
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Based on LPA observations conducted the licensee failed to ensure that the sharps are locked and inaccessible to clients which poses an immediate health and safety risk to clients in care.
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Type B
05/06/2022
Section Cited
CCR87211(a)(1)(D)

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87211(a)(1)(D) Reporting Requirements. Each licensee shall furnish... the following: A written report shall be submitted to the licensing agency...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)(D)Reporting Requirements and signed that she understands the Reporting Requirements. Administrator plans to ensure that incident reports will be submitted to CCL in a timely manner. Proof of correction to be submitted by POC due date of 05/06/2022.

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Based on interviews and record reviews the licensee failed to ensure that written reports of R5's aggressive behaviors towards residents R1 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:Eva M Alvarez
LICENSING EVALUATOR NAME:Don Senaha
LICENSING EVALUATOR SIGNATURE:
DATE: 04/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2022


LIC809 (FAS) - (06/04)
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