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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602274
Report Date: 08/29/2025
Date Signed: 08/29/2025 03:24:06 PM

Document Has Been Signed on 08/29/2025 03:24 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 ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
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:
08/29/2025
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:House Manager - Nelson OrtegaTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
NARRATIVE
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On 08/29/2025, the California Department of Social Services (CDSS) – Community Care Licensing Division (CCLD) Licensing Program Analyst (LPA) Socorro Leandro conducted an unannounced case management visit. The purpose of the visit was explained, and the LPA was allowed entry to the facility.

This facility is licensed to serve 6 non-ambulatory adults ages 60 and above, of which 2 may be bedridden. The facility has a hospice waiver for 6 residents. Bedroom #3 is cleared for 1 bedridden client

There are currently 4 residents in the facility.

Today’s unannounced case management visit focused on physical facility plant.

Facility Layout: The facility is a two-story house located on a main street. The first floor consists of - 3 resident bedrooms; 2 full bathrooms; 1 great room which consists of a kitchen area, dining room area, office space, and living room area; 1 attached garage with a laundry area. The second floor consists of - 3 staff bedrooms and 1 full bathroom. Outside - There is a front yard and back yard patio area with shaded seating.
Outside Grounds: were toured no bodies of water were observed, there are no security bars or weapons on the premises.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 08/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 08/29/2025 03:24 PM - It Cannot Be Edited


Created By: Socorro Leandro On 08/29/2025 at 02:26 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: 08/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/30/2025
Section Cited
CCR
87303(e)(2)

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Maintenance and Operation (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 than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
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The House Manager, Nelson Ortega, has agreed to decrease the hot water temperature and create a plan to ensure that hot water temperatures are maintained at 105 to 120 degrees Fahrenheit.
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Based on observation the licensee did not comply with the section cited above. Hot water temperature measured 135.5 degrees Fahrenheit. This violation poses an immediate health and safety risk to persons in care.
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Proof of correction will be emailed to Socorro.Leandro@dss.ca.gov
Type A
08/30/2025
Section Cited
CCR87303(b)(2)

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Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times. (2) The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat to 30 degrees F less than the outside temperature.

This requirement is not met as evidenced by:
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The House Manager, Nelson Ortega, has agreed to decrease indoor facility temperatures via providing more fans, coolers, etc. to residents and maintain indoor facility temperatures at 78 F to 85 F.
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Based on observation the licensee did not comply with the section cited above. Facility indoor temperatures measured 96.44 F, 94.28 F, and 93.77 F. This violation poses an immediate health and safety risk to persons in care.
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And create a plan to ensure that residents do not dehydrate, overheat, become heat exhausted, etc.

Proof of correction will be emailed to Socorro.Leandro@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.
Ulysses Coronel
NAME OF LICENSING PROGRAM MANAGER:
Socorro Leandro
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 08/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2025


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
EL SEGUNDO ASC, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SANTA FE HOME CARE IV
FACILITY NUMBER: 198602274
VISIT DATE: 08/29/2025
NARRATIVE
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Kitchen Area/Facility Food: The facility has supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. Knives and toxins were kept inaccessible to residents in care. There is a fire extinguisher in the kitchen area, and it was last serviced on 02/13/2025. At 1:42 PM the dining room area measured 96.44 degrees Fahrenheit; Resident 1 was sitting at the dining room table. There is a wall thermometer near the dining table, and it measured around 94 degrees Fahrenheit from 1:34 PM to 1:45 PM. There was a fan pointing to Resident 1. There was a portable cooler in the dining room area.
Community Indoor Space: There is a landline telephone and videoconferencing device in the office area. There are games/activity work (i.e. board games, books, magazines) for residents in the living room area.

Resident Bedrooms: 3 out of 3 resident bedrooms were toured. There is adequate lighting, plenty of dresser and closet space observed. Walls and floors were clean and in good condition. At 1:40 PM resident bedroom # 3 measured 94.28 degrees Fahrenheit; Resident 2 was sleeping in the room; there was a fan on in the room. At 1:43 PM resident bedroom # 1 measured 93.74 degrees Fahrenheit; Resident 3 was sleeping in the room; there was a fan on in the room.

Bathrooms: Toilets and sink faucets worked properly, grab bars were secure, and a non-skid mat was in place. Adequate lighting and toiletries accessible to residents. Bathroom 2 shower head was in disrepair. The hot water temperature in the downstairs bathroom between resident bedroom #1 and resident bedroom #2 measured 135.5 degrees Fahrenheit.

Medications: were inaccessible to residents in care.

Garage: is used as a storage area for live-in staff, residents, and extra facility supplies such as bed linens, toiletries, cleaning supplies, food, and etc.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025
LIC809 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 08/29/2025
NARRATIVE
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Miscellaneous: Smoke and carbon monoxide detectors were in compliance and operational.

Technical advisories are being provided regarding: keeping outside walkways free of obstruction; keeping upstairs walkways free of obstruction; keeping garage free of obstructions and clutter.

Deficiencies are being provided based on observations in accordance with the California Code of Regulations, Title 22, see LIC809D. Violations regarding hot water temperatures and indoor facility temperatures.

An exit interview was conducted, Plans of Corrections were reviewed and developed. A copy of this report and appeal rights were discussed and left with the House Manager, Nelson Ortega.
NAME OF LICENSING PROGRAM MANAGER: Ulysses Coronel
NAME OF LICENSING PROGRAM ANALYST: Socorro Leandro
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2025
LIC809 (FAS) - (06/04)
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