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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602274
Report Date: 12/28/2023
Date Signed: 12/28/2023 12:24:00 PM

Document Has Been Signed on 12/28/2023 12:24 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, 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:
12/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Nelson Ortega/CaregiverTIME COMPLETED:
12:23 PM
NARRATIVE
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On 12/28/2023, Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Nelson Ortega/Caregiver and later Virgina Asis/Designee Administrator. LPA explained the purpose of today’s visit. The facility is licensed to serve (6) non-ambulatory elderly adults ages 60 and above and approved hospice waiver for (6). (2) May be bedridden. Bedroom #3 is cleared for (1) bedridden client.

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 Iniguez toured the physical plant with administrator. There were no bodies of water or obstructions on the premises. A total of (3) rooms were inspected. Beds and bedding supplies were in good condition, adequate lighting was provided, and storage for the residents’ personal belongings was observed. Bathrooms were found to be within Title 22 regulations and were operational. LPA inspected rooms: #1, #2, and #3. smoke and carbon monoxide combo are all operable conditions. The water temperature ranged from 102.5F° – 118.2F°. The room temperature ranged from 76F° – 78F°.

Evaluation Report continues on LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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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, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SANTA FE HOME CARE IV
FACILITY NUMBER: 198602274
VISIT DATE: 12/28/2023
NARRATIVE
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LPA Iniguez observed the facility to be sanitary and appropriately furnished at the time of the visit. Storage areas for personal hygiene, cleaning supplies, toxins, and sharps objects were stored and not accessible to residents. The kitchen was inspected and there is sufficient perishable and non-perishable food available maintained properly. All fire extinguishers were charged and were operable. Working landline phones are available on-site. LPA reviewed (3) residents' service files (R#1-R#3) and (3) staff personnel files (S#1-S#3). Medication Administration Records (MAR) were maintained in order. First AID lit was checked. Last fire disaster drill was on: None. Licensee will email copy of liability insurance to LPA.

LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

Exit interview conducted with Ortega Nelson /Caregiver and a copy of the appeal rights were given at the time of the visit.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 12/28/2023 12:24 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 12/28/2023 at 11:57 AM
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: 12/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

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 in having the bathroom ceiling in disrepair which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/16/2024
Plan of Correction
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Licensee will ensure facility is in good repair at all times. Also, Licensee will fix the bathroom ceiling, when done licensee will submitt proof of correction to LPA via email before POC due date.
Type B
Section Cited
HSC
1569.618(a)
Other Provisions
(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews the licensee did not comply with the section cited above in having an administrator designee promptly available at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/09/2024
Plan of Correction
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Licensee will ensure administrator designee is available at all times at the facility. In addition, licensee will ensure designee is promptly available at the facility during regular business hours and will choose another designee.
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:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 12/28/2023 12:24 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 12/28/2023 at 11:57 AM
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: 12/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation record review, the licensee did not comply with the section cited above in having expired CPR card in staff files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/09/2024
Plan of Correction
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Licensee will ensure all staff CPR cards are updated. In addition, licensee will submitt the new CPR cards to LPA before POC due date via email.
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation record review, the licensee did not comply with the section cited above in having resident's admission agreement form other home and not the current one which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/09/2024
Plan of Correction
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Licensee will ensure all residents have a current admission agreement. In addition, licensee will submitt corrected admission agreement to LPA via email before POC due date.
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:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 12/28/2023 12:24 PM - It Cannot Be Edited


Created By: Alfonso Iniguez On 12/28/2023 at 11:57 AM
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: 12/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(16)
Resident Records
(b) Each resident's record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview record review, the licensee did not comply with the section cited above in having the SPV form done on the residents files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/09/2024
Plan of Correction
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Licensee will ensure all residents have their SPV forms on files. In addition, licensee will submitt proof of correction to LPA via email before POC due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

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 having proof of quaterly disaster drills when requested by LPA which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 01/09/2024
Plan of Correction
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Licensee will ensure facility disaster drills are available at the facility at all time. In addition, licensee will submitt proof of facility disaster drill to LPA via email before POC due date.
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:Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023


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