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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602274
Report Date: 08/22/2022
Date Signed: 08/23/2022 03:22:04 PM

Document Has Been Signed on 08/23/2022 03:22 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 IVFACILITY NUMBER:
198602274
ADMINISTRATOR:GRADNEY, ANGELIQUEFACILITY TYPE:
740
ADDRESS:5010 TORRANCE BLVDTELEPHONE:
(310) 316-0001
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY: 6CENSUS: 4DATE:
08/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:VIRGINIA ASIS/NELSON ORTEGATIME COMPLETED:
03:30 PM
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On 8/22/2022, Licensing Program Analyst (LPA) Lourdes Montoya conducted an unannounced annual required visit with a primary focus on Infection Control measures using the new CARE Inspection Tool. Upon arrival, LPA Montoya called the facility, spoke with Licensee Angelique Gradney and conducted a risk assessment. Based on the assessment, the facility is clear of Covid-19 infection.

LPA met with Facility House Manager (HM), Nelson Ortega, who granted access and allowed LPA to enter the facility to conduct an annual inspection. Administrator Virginia Asis joined the visit shortly after. Three clients and two caregivers along with the administrator were present in the facility during this inspection. One resident was out for a doctor's appointment.

Facility is licensed to serve 6 clients age range 60 and over. Approved for 6 non-ambulatory of which 2 may be bedridden, bedroom#3 is cleared for bedridden; approved for hospice waiver for 6 residents. The Annual Licensing Fees are current. Administrator Virginia Asis' administrator’s certificate #6035815740 expires 9/8/2023.

The home consists of two (2) floor levels: the first floor consists of 3 resident bedrooms all of which are shared rooms, 2 restrooms, kitchen, dining room, living room, and attached 2 car garage. The second floor consists of 3 bedrooms occupied by staff.

LPA Montoya toured and inside and outside grounds of the facility with HM Nelson Ortega and Administrator Virginia Asis. There were no bodies of water or obstructions on the premises. All rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, storage for resident personal belongings was observed. Bed linens, comforters, and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulations and were clean and operational. The water temperature measured 151.1 and 126.9 degree Fahrenheit in resident bathrooms on the first floor. A comfortable temperature was maintained in the facility.

Evaluation Report Continues on LIC 809-C
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 IV
FACILITY NUMBER: 198602274
VISIT DATE: 08/22/2022
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LPA observed the facility to be sanitary and appropriately furnished at the time of visit. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. The facility has (2) fire extinguishers that were last serviced on 2/23/22; smoke detectors, and carbon monoxide were operable. The facility conducted a Fire/Safety Drill on 7/23/2022. A working telephone 310-316-0001 remains available.

During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, and sanitizing stations in common areas and restrooms. LPA observed staff were wearing face coverings, LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted. The facility has an approved Mitigation Plan Report on file with CCLD.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed a deficiency and issued a citation on LIC 9099D.

Exit interview was conducted and a copy of this report and Appeal Rights were provided to House Manager Nelson Ortega.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/23/2022 03:22 PM - It Cannot Be Edited


Created By: Lourdes Montoya On 08/22/2022 at 02:41 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: 08/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less that 105 degree F and not more than 120 degree Fahrenheit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA Montoya observed the water temperature in bathroom #1 next to resident bedrooms #1 & #2 is 151.1 degree F and the water temperature in bathroom #2 next to resident bedroom #3 is 126.9. degree F. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2022
Plan of Correction
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The administrator shall ensure the water temperature is always within compliance. The administrator shall test and record the water temperature every two hours within the next 24 hours and submit the records of the temperature to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Lourdes Montoya
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2022


LIC809 (FAS) - (06/04)
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