198602274-1-25-2024-11-AS-EMAZ-D22UZG-20240201150130

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198602274
Report Date: 01/25/2024
Date Signed: 01/25/2024 03:04:49 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/22/2024 and conducted by Evaluator Wendy Gibbs

COMPLAINT CONTROL NUMBER: 11-AS-20240122091659

FACILITY NAME:	SANTA FE HOME CARE IV		FACILITY NUMBER:	198602274
ADMINISTRATOR:	GRADNEY, ANGELIQUE		FACILITY TYPE:	740
ADDRESS:	5010 TORRANCE BLVD		TELEPHONE:	(310) 316-0001
CITY:	TORRANCE	STATE: CA	ZIP CODE:	90503
CAPACITY:	6	CENSUS: 4	DATE:	01/25/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Nelson Ortega		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

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Saff are not allowing resident to have visitors

INVESTIGATION FINDINGS:

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On 01/25/24, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced complaint visit to the facility listed above. LPA met with House Manager, Nelson Ortega, and the purpose of today's visit was explained.
During today's visit, LPA toured the facility, received documents pertinent to the investigation, interviewed Staff (S1-S4), interviewed Residents (R1-R4), and Resident's POA. Documents received and reviewed are the Admission Agreement (12. Facility Visiting Policy), resident Identification and Emergency Information, Visitor Logbook, and Prevention, Containment, Mitigation Measures for Coronavirus Disease 2019 (Covid-19).

The investigation revealed the following:

Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 11-AS-20240122091659

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/25/2024

NARRATIVE

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Allegation: Saff are not allowing resident to have visitors.

The allegation alleges that the staff are sick and not allowing visitors to visit Residents during the weeks of 01/07/24 to 01/20/24.

During file review, LPA reviewed the Visitor Logbook that show visitors during the weeks of 01/07/24 to 01/20/24. During interviews with Staff (S1 and S2), two (2) out of two (2) stated during those dates’ residents had a cough and a fever. S1 stated the families were notified, residents were tested for Covid-19, and we were isolating until residents had a second negative Covid-19 test to make sure. Additionally, S1 stated once residents were tested negative, we let families know and they had visitors. When visitors came, we did let them know if their resident was sick but we never denied entry. Staff S1, additionally stated, some of the resident’s families dropped items off for the resident. S1 stated the only visiting restrictions we have is for Resident R2 who has a visitor list that the Responsible Party has listed of who is able to visit R2 and if they are not on the list R2’s Responsible Party will inform staff a visitor is coming, including friends, family, and medical providers. During interviews with Residents (R1-R4), four (4) out of four (4) stated they have been informed of the Visitor Policy, have no concerns regarding the Visitor Policy, and have had no issues with friends, family, or medical providers visiting. R1 and R3 stated there were a few days they did not have visitors due to a cough and fever and they made sure it was not Covid-19, and visitors came after that.

Continued on LIC9099-C

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 11-AS-20240122091659

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/25/2024

NARRATIVE

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LPA spoke with R3’s Responsible Party, who stated they have no concerns regarding the Facility Visiting Policy, and that staff called and informed them R3 was sick and kept them posted on testing, R3’s condition, and ensured they were able to speak on the phone. Additionally, R3’s Responsible Party stated staff informed them when R3 was confirmed not to have Covid-19 and when they were able to return for visiting. LPA reviewed the Facility Visiting Policy (#12 in the Admission Agreement) that states the hours and protocol of visiting. Upon review of the Prevention, Containment, Mitigation Measures for Coronavirus Disease 2019 (Covid-19) that states on number 7. “We will be restricting individuals who have respiratory Symptoms or potential Covid-19 exposure out of an abundance of caution…” During the course of the investigation, LPA was unable to find any evidence supporting the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the above allegation did or did not occur, therefore the allegation is unsubstantiated.

During today's visit, LPA did not observe or cite any deficiencies.

An exit interview was conducted with House Manager, Nelson Ortega, and a copy of this report was provided.

SUPERVISOR'S NAME: Eva M Alvarez	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR NAME: Wendy Gibbs	TELEPHONE: (323) 981-1755
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

LIC9099 (FAS) - (06/04)

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