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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602274
Report Date: 10/03/2024
Date Signed: 10/03/2024 07:09:56 PM

Document Has Been Signed on 10/03/2024 07:09 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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
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: 4DATE:
10/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Nelson Ortega & Virginia AsisTIME VISIT/
INSPECTION COMPLETED:
04:01 PM
NARRATIVE
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On 10/03/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with house manager Nelson Ortega. LPA explained the purpose of today’s visit. Ortega contacted the administrator Virgina Asis who later was present during the visit. The facility is licensed to operate for (6) non-ambulatory of which (2) maybe bedridden elderly adults ages 60 and above. Currently, the facility has no hospice resident in care. The facility is approved for (6) hospice residents.

The facility 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 toured the physical plant. There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the resident's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 114.8 degrees F. A comfortable temperature of 77 degrees F. was maintained in the facility.

LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene and sharps objects were stored and not accessible to residents. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Fire extinguisher were charged. The facility has conducted emergency fire drills on 04/06/24. A review of the Medication Administration Record (MAR) was observed to be maintained in order.

(Evaluation Report continues LIC 809-C)
SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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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Document Has Been Signed on 10/03/2024 07:09 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 10/03/2024 at 01:54 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SANTA FE HOME CARE IV
FACILITY NUMBER: 198602274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 identified (1) disinfectant spray left on top of a trash bin accessible to resident in care with Demential. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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Licensee will ensure that all disinfectants, cleaning solutions, poisons and other harmful items pose a danger to residents in care are not accessible to residents stored away in locked storage cabinets. Proof of correction must be sent by due date to ernand.dabuet@dss.ca.gov
***corrected during visit***
Type A
Section Cited
CCR
87303(a)
Care of Persons with Dementia
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 . LPA identified smoke detector in Room #1 is not operable. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/04/2024
Plan of Correction
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Licensee will ensure that all emergency devices as smoke detectors are in working condition. Licensee to repair or replace smoke detector device as a correction. Proof of correction must be sent by due date to ernand.dabuet@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.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/03/2024 07:09 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 10/03/2024 at 01:56 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SANTA FE HOME CARE IV
FACILITY NUMBER: 198602274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, record review and interview, the licensee did not comply with the section cited above. LPA identified resident #3 with dementia has full lenght bed rails. R3 is not on hospice care and did not have physicians prescription for bed rails. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2024
Plan of Correction
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Licensee will ensure to adhere to Title 22 Reg 87608 and remove full length bed rails. Proof of correction of physicians prescription is needed to maintain full lenght bed rails. Proof of correction must be sent by due date to ernand.dabuet@dss.ca.gov
Type B
Section Cited
CCR
87705(c)(4)(A)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision.

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. LPA identified no night supervision "awake" staff for residents #1, #3 and #4 diagnosed with Dementia. ]This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2024
Plan of Correction
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Licensee will adhere to Title 22 Reg 87705 and ensure a night "awake" staff is available and add to Personnel Report schedule LIC 500. Proof of correction of a revised LIC 500 must be sent by due date to ernand.dabuet@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.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


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Created By: Ernand Dabuet On 10/03/2024 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SANTA FE HOME CARE IV
FACILITY NUMBER: 198602274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
(c) All window screens shall be clean and maintained in good repair.

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 identified resident room #2 did not have a window screen. This violation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2024
Plan of Correction
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Licensee will ensure that all windows have screens are maintained in good repair. Proof of correction is for licensee to purchase a window screen for room #2 by due date and to send a photo of correction to ernand.dabuet@dss.ca.gov
Type B
Section Cited
CCR
87411(c)(1)
(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. LPA identified staff #2 and #4 did not have current CPR/First Aid card in staff files which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2024
Plan of Correction
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Licensee will ensure all staff CPR cards are updated. In addition, licensee will submit the new CPR cards to LPA before POC due date via email to ernand.dabuet@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.
SUPERVISOR'S NAME:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


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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, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SANTA FE HOME CARE IV
FACILITY NUMBER: 198602274
VISIT DATE: 10/03/2024
NARRATIVE
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LPA observed First Aid Kit was maintained. A working landline phone was operational. The facility had operational smoke and carbon monoxide in bedrooms and common areas. The facility has current liability insurance on file effective 08/19/23 through 08/19/24. The facility is current with CCLD annual license dues.

An audit of residents #1-#4 (R1-R4) service files and staff #1-#4 (S1-S4) personnel files. The facility has the current administrator's certification on file for Virginia Asis #7010477740 Expiration 09/08/25.

DEFICIENCIES:
  • Non-operable smoke detector in resident room #1.
  • Disinfectant Spray left out on top of kitchen trash bin accessible to resident in care.
  • No window screen for resident room #2.
  • Staff #1 and #2 did not have direct care training completed.
  • Staff # 2 and #4 did not have current CPR/First Aid completed.
  • Resident #3 not on hospice care had full extended bed rails without physician's prescription.
  • Facility had no night "awake" staff for (3) out of (4) residents diagnosed with Dementia.

  • Civil Penalties issued for repeat violations.


According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiencies has been observed and citation issued (ref. LIC 809-D).

An exit interview conducted with Nelson Ortega, a copy of report and appeal rights provided.

Note: *Citations not cleared by the due date will be a $100 fine assessed for each citation until it is cleared. Civil penalties will continue to accrue until Proof of Corrections (POC) are cleared. *

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:

DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/03/2024 07:09 PM - It Cannot Be Edited


Created By: Ernand Dabuet On 10/03/2024 at 03:01 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
, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: SANTA FE HOME CARE IV
FACILITY NUMBER: 198602274

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.626(a)(1)
Training requirements for direct care staff All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff: (1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently with residents...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above. LPA identified staff #1 and #2 did not have completed direct care training completed on file. This violation which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/17/2024
Plan of Correction
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Licensee to coordinate training or train staff and document trainings. Licensee to submit the following to LPA by POC due date: sign-in sheet with staff/participant names and signatures, date of training, topic of training, duration of the training and curriculum used for the training to ernand.dabuet@dss.ca.gov
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:Janae Hammond
LICENSING EVALUATOR NAME:Ernand Dabuet
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
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