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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603410
Report Date: 04/03/2024
Date Signed: 04/03/2024 01:21:47 PM


Document Has Been Signed on 04/03/2024 01:21 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:LA CASITA RESIDENTIAL CARE INC.FACILITY NUMBER:
198603410
ADMINISTRATOR:SANTAMARIA, HUMBERTOFACILITY TYPE:
740
ADDRESS:700 N. GRAND AVE.TELEPHONE:
(626) 387-9987
CITY:GLENDORASTATE: CAZIP CODE:
91741
CAPACITY:6CENSUS: 6DATE:
04/03/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:28 AM
MET WITH:Humberto and Carmen Santa Maria TIME COMPLETED:
01:27 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted a Health and Safety check visit in response to complaint allegations. LPA was greeted by DSP Karla Enriquez who allowed entry. Administrator, Humberto Santamaria and Spouse Carmen Santamaria arrived a few minutes later and LPA explained the reason for the visit.

During the health and safety check, LPA observed several deficiencies. Four residents were observed with gait belts wrapped around the wheelchair without a quick release. LPA observed client using oxygen without a sign on the entrance and no report to provided to Fire Department. Carmen Santamaria, Spouse of Licensee stated that they have 4 residents on hospice but never notified the department of the initiation of Hospice services. Facility also failed to submit incident report(s) when resident(s) were hospitalized and death report for resident that passed away in January 2024.



California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the 809D exit interview held, report, citations, and appeal rights provided,
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
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 04/03/2024 01:21 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: LA CASITA RESIDENTIAL CARE INC.
FACILITY NUMBER: 198603410

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/04/2024
Section Cited
CCR
87608(a)(2)

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(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (2) Postural supports shall be fastened or tied in a manner that permits quick release by the resident.
This requirement is not met as evidenced by:
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Administrator will obtain quick release belts that are used as postural supports and send proof to LPA by POC date.
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LPA observed 4 residents wearing gait belts without a quick release which poses/pose a health and safety hazard for residents in care.
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Type B
04/05/2024
Section Cited
CCR87618(b)(3)(a)

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(a) Except as specified in Section 87611(a), the licensee shall be permitted to accept or retain a resident who requires the use of oxygen gas administration under the following circumstances:
(b) In addition to Section 87611(b), the licensee shall be responsible for the following:
(A) A report shall be made in writing to the local fire jurisdiction that oxygen is in use at the facility.
This requirement is not met as evidenced by:
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Administrator will send written report to fire department and send proof to LPA by POC date.
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LPA observed one resident using oxygen and no written report has been submitted to fire department.
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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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 04/03/2024 01:21 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: LA CASITA RESIDENTIAL CARE INC.
FACILITY NUMBER: 198603410

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
04/05/2024
Section Cited
CCR
87211(a)(1)(A)

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87211 Reporting Requirements; (a) Each licensee shall furnish...: (1) A written report shall be submitted to the licensing agency...within seven days of the occurrence... (A) Death of any resident from any cause regardless of where the death occurred...
This requirements is not met as evidence by:
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Facility will submit death report for R#1. Licensee and administrator to review reporting requirements regulations section 87211 by POC due date 4/05/2024
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Based on documents reviewed, and facility failed to report death of R#1 within the seven days of occurrence which poses a potential Health, Safety, and Personal Risk to persons in care.
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Type B
04/10/2024
Section Cited
CCR87632(d)(2)

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Hospice Care Waiver
The licensee shall notify the Department in writing within five working days of the initiation of hospice care services for any terminally ill resident in the facility or within five working days of admitting a resident already receiving hospice care services. The notice shall include the resident's name and date of admission to the facility and the name and address of the hospice.
This requirement is not met as evidenced by:
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Administrator will send notifications of initiation of hospice for four residents currently on Hospice.
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Facility has four residents currently on Hospice and failed to notify the department
which poses a potential Health, Safety, and Personal Risk to persons 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: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Alberto LopezTELEPHONE: 323-980-4926
LICENSING EVALUATOR SIGNATURE:
DATE: 04/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/03/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3