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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602274
Report Date: 12/10/2025
Date Signed: 12/10/2025 04:28:15 PM

Document Has Been Signed on 12/10/2025 04:28 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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:SANTA FE HOME CARE IVFACILITY NUMBER:
198602274
ADMINISTRATOR/
DIRECTOR:		GRADNEY, ANGELIQUEFACILITY TYPE:
740
ADDRESS:5010 TORRANCE BLVDTELEPHONE:
(310) 316-0001
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY: 6CENSUS: 6DATE:
12/10/2025
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Administrator - Angelique GradneyTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
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On 12/10/2025, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) staff conducted an unannounced Required – 1 Year Inspection to the above-named facility and met with Administrator, Angelique Gradney. The purpose of the visit was explained, and the LPA was allowed entry to the facility.

This facility is licensed to serve 6 non-ambulatory adults ages 60 and above, of which 2 may be bedridden. The facility has a hospice waiver for 6 residents. Bedroom #3 is cleared for 1 bedridden client.

A total of 6 residents are currently residing in this facility.

The facility paid their Annual Licensing Fees today.

Facility Layout: The facility is a two-story house located on a main street. The first floor consists of 3 resident bedrooms; 2 full bathrooms; 1 great room which consists of a kitchen area, dining room area, office space, and living room area; 1 attached garage with a laundry area. The second floor consists of 3 staff bedrooms and 1 full bathroom. Outside, there is a front yard and back yard patio area with shaded seating; and there is a storage room.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 12/10/2025 04:28 PM - It Cannot Be Edited


Created By: Socorro Leandro On 12/10/2025 at 02:22 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 IV
FACILITY NUMBER: 198602274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(a)
Personnel Requirements - General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in the facility not having continous night staff, according to records review facility residents requiere continous care and supervision, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/12/2025
Plan of Correction
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The Administrator has agreed to re-read residents physicians reports, care plans, and CCR87411(a). The Administrator has agreed to provide residents with continous 24 hour care.

The licensee will email LIC500 to Ulysses.Coronel@dss.ca.gov & Socorro.Leandro@dss.ca.gov

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:
Socorro Leandro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/10/2025 04:28 PM - It Cannot Be Edited


Created By: Socorro Leandro On 12/10/2025 at 02:22 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 IV
FACILITY NUMBER: 198602274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(3)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in not documenting the residents' response to the PRN medication which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/30/2025
Plan of Correction
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The Administrator has agreed to re-read CCR 87465. The Administrator has agreed to retrain staff on how to provide residents with PRN medication and document PRN medication.

Email proof of correction to Socorro.Leandro@dss.ca.gov
Type B
Section Cited
CCR
87628(a)
Diabetes
(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above, according to staff Resident 3 (R3) injected themselves through their assistance (according to R3's physicians report they are unable to inject themselves) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/10/2025
Plan of Correction
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The facility Administrator solved this issue.
On 12/05/2025, R3 was prescribed insulin pills. R3 is currently taking insulin pills.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:
Socorro Leandro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/10/2025


LIC809 (FAS) - (06/04)
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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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SANTA FE HOME CARE IV
FACILITY NUMBER: 198602274
VISIT DATE: 12/10/2025
NARRATIVE
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Outside Grounds: were toured no bodies of water were observed, walkways around the home were clear of hazards, and there are no security bars or weapons on the premises.

Kitchen Area/Facility Food: The facility has supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept inaccessible to residents in care. There is fire extinguisher in the kitchen and it was last serviced on 02/13/2025.

Great Room / Community Space: There is a landline telephone, fax machine, and a videoconferencing device in the office area. There are games/activity work (i.e. board games and books) for residents in the living room area.

Resident Bedrooms: 3 out of 3 resident bedrooms were toured. There is adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition.

Bathrooms: Toilets, showers, and water faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries are accessible to residents.

Medications: were inaccessible to residents in care. All medications observed were labeled and maintained in compliance with label instructions and State and Federal law. 6 out of 6 Medication Administration Records (MARs) were reviewed. Nonprescription (PRN) medication was documented but it did not include the resident’s response to the medication. 1 out of 6 residents were being provided with insulin injections by facility staff (this resident is currently taking insulin pills, according to staff resident injected themselves through their assistance).

Garage: has a laundry area, staff break room area, and holds extra facility supplies. Supplies such as, blankets, towels, pillowcases, cleaning supplies, incontinent care need supplies, etc.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025
LIC809 (FAS) - (06/04)
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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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SANTA FE HOME CARE IV
FACILITY NUMBER: 198602274
VISIT DATE: 12/10/2025
NARRATIVE
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Miscellaneous: Documents are posted as mandated. Last fire drill was conducted on 10/2/2025. The last Annual Fire Inspection by the Torrance Fire Department was conducted on 2/14/2025. First aid kit is fully stocked with manual. Smoke and carbon monoxide detectors were in compliance and operational. The facility liability insurance is current. Fumigators come to the facility once a month and provide services.

5 staff records were reviewed, 5 out of 5 staff records had required documentation. Night staff are on call / live in and according to staff they are only paid during the times they work for example if a resident requires assistance than the night staff will assist a resident.

6 resident records were reviewed, 6 out of 6 resident records had required documentation.

Physicians Report for the Resident 1 to Resident 6 indicate the following:

Resident 1 – Nonambulatory

Resident 2 – Severe Cognitive Impairment; Comorbidities; Unstageable heel pressure ulcer; Incontinent; Motor Impairment/Paralysis; Requires Continuous Bed Care; History of Skin Condition or Breakdown; Needs Assistance with Activities of Daily Living (ADL); Nonambulatory

Resident 3 – Dementia; Diabetes; Treatment - Insulin PEN; Severe Late Onset Alzheimer’s Dementia; Hearing Loss; Incontinent; Requires Assistance with Repositioning and Transferring; Not able to: bathe self, dress/groom self, manage own toileting needs; Disorientation; Lack of Impulse Control; Expressions of Frustration; Patient bed bound; Not able to Manage own medications; Bedridden
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025
LIC809 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SANTA FE HOME CARE IV
FACILITY NUMBER: 198602274
VISIT DATE: 12/10/2025
NARRATIVE
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Resident 4: Sepsis/UTI; Mild Cognitive Impairment; Confused Disoriented; At Risk if Allowed Direct Access to Personal Grooming and Hygiene Items; Not able to care for own toileting needs
Resident Appraisal 10/31/2025: Needs special observation/night supervision

Resident 5: Multiple diagnosis; Mild Cognitive Impairment; Bowel & Bladder Impairment; Confused/Disoriented; Sundowning Behavior; Not able to care for Self-Care includes toileting needs and self-grooming

Resident 6: Dementia; Hypertension; Incontinent Urinary; Requires Supervision; Motor Impairment/Paralysis - Weakness; Requires Continuous Bed Care; History of Skin Condition or Breakdown; At Risk if Allowed Direct Access to Personal Grooming and Hygiene Items; Not able for Self-Care including toileting, bathing, grooming

Technical violations are being provided regarding emergency quarterly drills.

Deficiencies are being cited based on observation, interviews conducted, and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. Violations regarding PRN medications, injections, and night staff.

An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the Administrator, Angelique Gradney.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2025
LIC809 (FAS) - (06/04)
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