Santa Fe Home Care II

Type of visit: Required - 1 Year

On 08/20/2025, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with the Administrator Virginia Asis and Administrator Assistant Rodolfo Lozada. The facility is licensed to serve six (6) non-ambulatory residents age 60 and over. The facility has a hospice waiver approved for six (6) residents. The facility currently has four residents with Assisted Living Waivers (one resident pending approval). Annual Fees are current. The facility is a single-story house located in a residential neighborhood and consists of three (3) bedrooms, two (2) bathrooms, family room/activity area, kitchen, dining area, and staff room. Administrator Assistant accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. The facility is clean, sanitary, and in good repair. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Continue to LIC809-C. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, and hot water temperature properly measured at 107.6 F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Common areas were clean and clear of hazards and doorways were free of obstructions. LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in locked storage cabinet. First Aid kit was available. Two fire extinguishers, last serviced February 13, 2025 was observed in the kitchen and in the laundry room. Staff tested the carbon monoxide detector and smoke detectors in the house. Both devices were functional. Five staff records were reviewed, five out of five staff records had current first aid certificates and required criminal record clearances or criminal record exemptions. Five resident records were reviewed and, five out of five resident records had medical assessments and pre-appraisal or reappraisals. Two residents’ medication was reviewed. Deficiencies are being cited based on California Code of Regulations, Title 22; see LIC809-D. During medication review, Resident #2 (R2) only had iron tablets in stock. However, R2’s medical assessment revealed R2 as diabetic. Interview with Staff indicated that R2’s insurance will not cover R2’s medication. The facility’s medication policy (medication refills) indicates medications are never allowed to run out unless directed to by the physician (obtain this direction in writing). Continue to LIC809-C. The plan of operation filed with Community Care Licensing Division (CCLD) does not match the plan of operation at the facility. An exit interview was conducted, plans of correction developed, technical assistance provided and a copy of this report with appeal rights was discussed and left with Administrator Assistant Rodolfo Lozada.the state’s words, verbatim · CDSS document, Aug 20, 2025

Type of visit: Case Management - Other

On 07/09/25, Licensing Program Analyst (LPA) Regina Cloyd conducted a Case Management - Other visit at this facility. LPA met with Staff who allowed for entry in this facility. LPA informed Staff the purpose of the visit is to conduct a case management - other visit in association with the noncompliance conference (NCC) with the Licensee on 11/24/2024. Administrator Virginia Asis and Licensee Angelique Gradney joined us later. The facility is licensed for six non-ambulatory residents over the age of 60 and has a hospice waiver for six residents. LPA and staff conducted a facility tour and LPA reviewed five resident records. Both staff members were associated with the facility. No deficiencies were observed. An exit interview was conducted and a copy of this report was provided to the Licensee Angelique Gradney.the state’s words, verbatim · CDSS document, Jul 9, 2025

Type of visit: POC

On 08/22/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a Plan of Correction (POC) and was met by caregiver Sonny Garalde. The purpose of the visit is to follow-up on the Plan of Correction that was due on 08/08/24 during Require Annual Inspection. The facility had an individual working as a staff # (S1) who did not have Criminal Clearance Background and was cited for 87355(e)(1). Based on observation, LPA was greeted by staff (S1) who still does not have a Criminal Clearance Background was observed assisting resident #1 (R1) out of the community at 3:00 pm. (S1) stated to be on-call reliever and is being paid by Santa Fe Home Care. Based on the information provided by the administrator, the facility violates the California Code of Regulations (Title 22, Division 6, Chapter 8), deficiencies were observed, and citations were issued (ref. LIC 9099-D). An exit interview was conducted with Sonny Geralde and a copy of the Evaluation Report and Appeal Rights were provided.the state’s words, verbatim · CDSS document, Aug 22, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Aug 23, 2024

(e) All individuals subject to a criminal record review... shall prior to working... in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above for one staff which poses an immediate safety risk to persons in care. LPA did not observe staff #1 (S1) having a criminal background clearance nor association to the facility. S1 worked in the facility on 08/22/24.the state’s words, verbatim · CDSS document, Aug 22, 2024

Plan of correction: The Licensee will email S1 criminal background clearance and Guardian association to the facility to ernand.dabuet@dss.ca.gov by the POC due date. The Licensee will esnure that all staff complete their background checks and are associated to the desginated facility.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(b)(2) · Plan of correction due date: Sep 5, 2024

87405(b)(2) Administrator - Qualifications and Duties. (b)The administrator of a facility or facilities shall have the responsibility and authority to carry out the policies of the licensee. (2)Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement was not met as evidenced by: Based on interview and observation the Licensee/Administrator failed to adhere to Title 22 regulations, resulting to multiple deficiencies cited, which poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 22, 2024

Plan of correction: The licensee will create a plan to ensure that the administrator performs knowledge of and conforms to applicable laws, rules and regulations. Plan of correction will be submitted by POC due date: 09/05/24 to ernand.dabuet@dss.ca.gov

Type of visit: Case Management - Annual Continuation

On 08/08/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an annual continuation and met with Caregiver Mignon Diaz. LPA Cloyd spoke with Administrator Virginia Asis over the phone. The facility is licensed to serve clients aged 60 and over, six non-ambulatory. They have an approved Hospice Waiver for six residents. Annual Fees are current. The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) bedrooms, 2 bathrooms, living room, kitchen, dining room, family room, garage, and a shaded area. On 08/07/24, the Caregiver and Administrator accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Resident bedrooms had the required bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked. Continue to LIC809-C. Common areas were clean and clear of hazards, doorways were free of obstructions. LPA toured the kitchen area and observed knives and toxics were kept in locked storage cabinet. First Aid kit was available. One fire extinguisher, last serviced August 11, 2023 was observed in the kitchen area. Staff tested the smoke detectors in the house. Device was functional. Two (2) resident records were reviewed and, 2 out of 2 resident records had medical assessments. Two residents’ medication was reviewed. Four (4) staff records were reviewed. Deficiencies are being cited based on LPA observation, interviews conducted and record review in accordance with the California Code of Regulations, Title 22, see LIC809D. A violation regarding criminal record clearance warrants an immediate civil penalty of $500.00 and is hereby assessed, see LIC421IM. On 08/07/24, LPA Cloyd did not observe Staff #5’s (S5) health screening with TB results nor criminal record clearance and association to the facility. The facility did not have a personnel record on site for S5. S5 was working at the facility on 08/07/24 and 08/08/24. On 08/07/24, during record review, LPA did not observe an allowable health care plan for resident #1 (R1). Interviews confirmed that R1 requires assistance with injections from the Home Health Nurse and from the staff. On 08/07/24, during the facility tour, LPA measured water temperate at 142.8. Staff adjusted the water temperature on 08/07/24 afternoon.. Continue to LIC809C. An exit interview was conducted , plans of Correction were developed, technical assistance provided, and a copy of this report and appeals was discussed with Administrator Virginia Asis and left with Caregiver Mignon Diaz.the state’s words, verbatim · CDSS document, Aug 8, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(3) · Plan of correction due date: Aug 7, 2024

(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in one bathroom which poses an immediate safety risk to persons in care. LPA Cloyd measured the water temparture at 142.8 degrees F.the state’s words, verbatim · CDSS document, Aug 8, 2024

Plan of correction: The staff adjusted the water heater and on 08/08/24, LPA Cloyd measured the water teamperature to be at 112 degree F. The Licensee will create a water temperature log for monthly readings and will email it to regina.cloyd@dss.ca.gov.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87355(e)(1) · Plan of correction due date: Aug 9, 2024

(e) All individuals subject to a criminal record review... shall prior to working... in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department or... This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above for one staff which poses an immediate safety risk to persons in care. LPA did not observe staff #5 (S5) having a criminal background clearance nor association to the facility. S5 worked in the facility on 08/07/24 and 08/08/24the state’s words, verbatim · CDSS document, Aug 8, 2024

Plan of correction: The Licensee will email R5's criminal background clearance and Guardian association to the facility to regina.cloyd@dss.ca.gov by the POC due date. The Licensee will esnure that all staff complete their background checks and are associated to the desginated facility.

Type of visit: Required - 1 Year

On 08/07/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Caregiver Mignon Diaz. The Administrator Virginia Asis arrived later. The facility is licensed to serve residents aged 60 and over, six non-ambulatory. They have an approved Hospice Waiver for six residents. Annual Fees are current. The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) bedrooms, 2 bathrooms, living room, kitchen, dining room, family room, garage, and a shaded area. The Caregiver and Administrator accompanied LPA inside and outside the facility during this inspection. Two (2) resident records were reviewed and, 2 out of 2 resident records had medical assessments. Two residents’ medication was reviewed. Four (4) staff records were reviewed. Deficiencies were observed. Due to insufficient time, an annual continuation is required. An exit interview was conducted and a copy of this report was discussed with Administrator Virginia Asis and left with Caregiver Mignon Diaz.the state’s words, verbatim · CDSS document, Aug 7, 2024

Type of visit: Case Management - Health Checks

On 06/04/24, Licensing Program Analyst (LPA) Regina Cloyd conducted a Case Management Health & Safety visit at the facility mentioned above. LPA was welcomed by staff Lucy Denzell and LPA called Licensee Angelique Gradney by telephone to explain the purpose of today's visit. At 10:54 AM, Ms. Gradney explained that the facility had a sink disposal and piping problem. She indicated that the plumbing began to leak to the side of the house, into the neighbor's house, and it caused a foul odor. Ms. Gradney's first vendor was unable to resolve the problem so it resulted in a bigger project. Ms. Gradney stated that she decided to go ahead and complete the plumbing, painting, and tent the facility for termites, 06/05/24, all at once. She stated that the project started two weeks ago. Ms. Gradney confirmed that there were no residents present and notice of work and move of resident was not provide to Community Care Licensing. Resident #1 (R1) was relocated to Santa Fe Home Care Homes #198205144 on 05/13/24. Resident #2 (R2) voluntarily moved prior to the construction on 04/08/24. LPA Cloyd observed the facility being remodeled and under construction. Based on the telephone interview and LPA observation, the facility violates the California Code of Regulations (Title 22, Division 6, Chapter 8), deficiencies were observed, and citations were issued (ref. LIC 9099-D). An exit interview was conducted and a copy of the Evaluation Report and Appeal Rights were provided to Lucy Denzell.the state’s words, verbatim · CDSS document, Jun 4, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87224(f) · Plan of correction due date: Jun 10, 2024

(f) A written report of any eviction shall be sent to the licensing agency within five (5) days. This requirement is not met as evidenced by: Based on interview and observation, the licensee did not comply with the section cited above for Resident #1 (R1) which poses a potential personal rights risk to persons in care. Licensing did not receive notice from the facility regarding R1's permanent move.the state’s words, verbatim · CDSS document, Jun 4, 2024

Plan of correction: The Licensee will provide a written report of Resident #1's eviction to regina.cloyd@dss.ca.gov by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Jun 19, 2024

(a) 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: Based on interview and observation, the licensee did not comply with the section cited above which poses a potential safety and personal rights risk to persons in care. LPA observed the facility being remodeled and under construction.the state’s words, verbatim · CDSS document, Jun 4, 2024

Plan of correction: The Licensee will provide evidence for meeting this regulation prior to the POC due date. Plan of correction to be emailed to regina.cloyd@dss.ca.gov

Allegation investigated: Staff are not meeting resident's hygiene needs. Staff are leaving resident in urine-soaked items for an extended period of time resulting in wounds and skin tears.

On 06/02/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent complaint visit. LPA was greeted by (staff #1: Lucy Dezell). Dezell contacted administrator (A1:Virgina Asis) who could not be present during this visit. LPA explained the purpose of today's visit is gather information for the allegations mentioned above and deliver findings. The investigation consisted of the following: LPA obtained copies of the roster for residents and staff. Service records for resident #1 (R1), and other pertinent documents associated with this complaint. Interviews with the administrator, staff #1-#3 (S1-S3), residents #2-#5 (R2-R5), and witnesses #1-3 (W1-W3). A tour of the physical plant on 09/14/23, 0928/23 and 06/02/24. (Evaluation Report continues LIC 9099-C) Unsubstantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #4: Staff are not meeting resident's hygiene needs. Allegation #5: Staff are leaving resident in urine-soaked items for an extended period of time resulting in wounds and skin tears. The details of this complaint alleged staff are not meeting resident #1 (R1)’s hygiene needs which includes leaving (R1) in urine-soaked diapers for a long period that resulted in wounds and skin tears. The complainant reported (R1) appeared to be unclean, had nails with fecal items, and had hair matted, dirty, and unkempt. The complainant claimed (R1) has not been changed for an extended period and had an extensive amount of urine, as an indication of (R1) not being changed regularly. The complainant stated (R1) that wounds and skin tears may contribute to poor and neglectful handling. The complainant did not have further details information on these allegations as to the dates, time, and staff involved. The investigation revealed resident #1 (R1)’s Identification and Emergency Information LIC601 (dated: 08/23/22) and Admission Agreements for Residential Care Facilities for the Elderly (dated: 08/23/22), (R1) was admitted at Santa Fe Home II on 08/23/22. As outlined in (R1)'s Faith & Hospice & Palliative Care Inc Patient Profile (dated: 08/24/22) care services began on 08/24/22. (R1) voluntarily terminated residency at this facility on 09/20/23. On 09/28/24, between 9:30 am – 1:07 pm, the Department interview (3) out (3) administrator (A1) and staff #1-#3 (S1-S3) denied these allegations. (A1) and (S1-S3) all confirmed that (R1) was under hospice care a home aide would come to assist with hygiene and grooming care. Hospice aides and nurses monitor vital signs and personal hygiene three times a week. The facility staff would step in when (R1) refused hygiene and grooming services from a hospice home aide. (A1) claimed that (R1) was entitled to (R1’s) personal rights. There were often when (R1) declined to receive assistance with hygiene and grooming care from staff. The staff is respectful of (R1’s) rights and has the right to refuse such basic services. (A1) and (S1-S3) claimed that (R1) was repositioned, monitored, or changed at least every two hours or as needed. (S1-S3) denied leaving (R1) in urine-soaked diapers for an extended period. (S1-S3) communicated even at night shift hours of 11 pm – 6 am there is a staff on shift to attend to (R1)’s incontinence needs. (Evaluation Report continues LIC 9099-C) (A1) stated that (R1) was previously cared for at a skilled nursing facility and when admitted at Santa Fe Home Care II, (R1) already had minor skin tear. (A1) indicated that under hospice plan of care, a wound care plan was included. The wound care plan included to reposition, keep (R1) clean, dry and apply barrier cream every two hours. (A1) communicated that (R1) was under professional supervision and care with nurses and doctors while (R1) was at Santa Fe Home II. (R1)’s family members were at the facility during hospice visits with nurses discussing (R1’s) condition. (A1) stated when it came to (R1)’s medical needs it was always taken care of by hospice medical professionals. (A1) claimed the facility staff were only responsible for (R1)’s non-medical care since the facility is a non-medical care facility. On 09/28/24, between 10:45 am – 11:37 am, the Department interviewed (4) out (4) residents #2-#4 (R2-R4) all claimed that staff are responsive and are observant to resident's changes in condition and needs. (R2-R4) reported that when they require assistance, the staff is available even during the night shift. (R2) who is independent and shared a room with (R1) has observed that (R1)’s incontinence, hygiene, and grooming needs are being attended to timely by hospice and staff at the facility. On 09/28/24, between 9:47 am – 04:07 pm, the Department interviewed (3) out (3) family representatives witness #2-#4 (W2-W4) claimed the facility appeared to be adequately staffed. (W2-W4) who are very much involved with resident care at this facility with frequent visits and have not witnessed any activity of neglect or lack of care toward residents. (W2-W4) claimed (R2-R4) have not endured wounds while in care. Several telephone calls were made to family representatives for (R1), witnesses #1 and #5 (W1 and W5), but no comments were obtained. On 09/14/24, between 10:37 am – 10:57 am, the Department attempted to interview resident #1 (R1). Due to (R1)’s health condition, (R1)'s ability to make full statements or carry on a conversation was limited. (R1)’s appearance was presentable. (R1) appeared to be in clean clothing and groomed. Between 12:00 pm – 01:00 pm, the Department observed the hospice aide as well as staff #2 (S2) assisting with (R1’s) incontinence needs, grooming, and changing sheets for maintaining good hygiene. Faith & Hope Hospice & Palliative Care did not return several telephone calls and could not provide additional records. (Evaluation Report continues LIC 9099-C) According to Faith & Hope Hospice & Palliative Care records Flow Sheet (dated: 07/11/23 through 09/19/23) and Visitation Logs (dated: 05/11/23 through 09/19/23) verified visits occurred weekly. A Patient Medical Profile (dated: 08/24/22) confirmed that a care plan for (R1) illustrates the needs and services supplied by hospice. Physicians Report LIC 624A (dated: 08/05/22) and Appraisal/needs and Services Plan LIC 625 (dated: 08/05/22) revealed (R1) is not able to self-care and requires assistance with bathing, grooming, and toileting. In addition, the complainant expressed concerns that individuals who are acquaintances of facility staff wandered freely through the facility without supervision. Interviews with the facility staff, residents, and family representatives as well as a review of the Visitation Log were unable to support this claim. Based on the evidence gathered, interviews conducted, and analysis of records, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur; therefore, the allegations of NEGLECT/LACK OF SUPERVISION: “Staff are not meeting resident's hygiene needs” and “Staff are leaving resident in urine-soaked items for an extended period of time resulting in wounds and skin tears” are determined to be UNSUBSTANTIATED. An exit interview has been conducted and a copy of the Complaint Report was provided to the staff #1 (Lucy Dezell).the state’s words, verbatim · CDSS document, Jun 2, 2024 · control 11-AS-20230911101639

Allegation investigated: Staff did not dispense medication as prescribed Staff did not provide resident with special diet according to resident’s health care needs

On 05/06/24, Licensing Program Analyst (LPA), Wendy Gibbs conducted a subsequent visit to the facility listed above to deliver findings for a complaint. LPA met with care staff Rey Malit, and the purpose of today’s visit was explained. During today’s visit there were two residents present. During today’s visit, LPA toured the facility and reviewed the report with staff. On a previous visit conducted on 06/27/23, LPA toured the facility, interviewed staff S1, interviewed Resident R1, and received documents pertinent to the investigation. LPA received copies of pertinent documents including staff roster, client roster, residents Pre-Appraisal, Needs and Service Plan, Dietary Orders, Physicians Report, Doctors Orders, Medication Administration Record, staff notes, hospital discharge papers, shower schedule and menu. On a visit conducted on 10/20/23, LPA interviewed Staff S2 and S3, and interviewed Residents R2-R5. The investigation revealed the following: Substantiated Allegation: Staff did not provide resident with special diet according to resident’s health care needs. The allegation alleges that some residents have a special diet and the meals served are high in fat, sodium, and carbohydrates. During interviews with staff (S1-S3), were asked if residents special diet orders are followed, three (3) out of three (3) stated they follow resident’s special diets from their physicians. Interviews with Residents (R1-R5) three (3) out of five (5) stated they do not have any dietary restrictions. Residents R2 and R5 stated they have dietary restrictions and that they are served things they should not be eating due to their health conditions. R5 stated they are served sandwiches on white bread with high sodium meats. R1 stated they are given carbohydrates LPA reviewed physician’s orders for R1, R2, and R5, and found they required a special diet of low sodium, low carbohydrates, and low sugar. LPA reviewed the sample menu and observed many of the item are high in carbohydrates. Allegation: Staff did not dispense medications as prescribed The allegation alleges that medications are not properly dispensed even after doctors and nurses have conferenced with onsite caregiver. During record review of the Resident’s medication administration record (MAR), LPA observed the MAR did not have accurate documentation of medications administered to residents. Additionally, LPA observed R1 has two (2) PRN medications that are “take as needed” and there is no MAR indicating if or when resident took the medications. During record review, LPA observed on R1’s Physician’s Report they cannot manage their own medications. During interviews with Staff S1-S3, were asked if residents are given their medications as prescribed, three (3) out of three (3) stated residents medications are given as prescribed. During interviews with Residents R1-R5, were asked if they receive their medications as prescribed, four (4) out of five (5) stated they receive their medications as prescribed, and R3 stated they handle their own medications. During the course of the investigation, LPA was able to find evidence to support the allegation. Based on LPAs observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California code of Regulation, (Tittle 22, Division 6 & Chapter number 8), are being cited on the attached LIC 9099D. An exit interview was conducted with Staff, Rey Malit, and a copy of this report was provided. Allegation: Staff inappropriately touched resident. The allegation alleges that a staff might have touched a resident inappropriately. During interviews with Staff (S1- S3), were asked if they or another staff have touched a resident inappropriately, three (3) out of three (3) stated they have not touched any resident inappropriately, nor have they heard of resident being touched inappropriately. Additionally, Staff stated the only time they touch a resident is to provide care and if they are helping a resident with incontinent care or bathing, they ensure there is second staff in the room to assist. During interviews with Residents (R1-R5), were asked if staff have touched them inappropriately, five (5) out of five (5) residents stated they have not been touched inappropriately by staff. Residents have no concerns regarding their safety with staff. LPA reviewed past SIRs and past complaints and did not find any incidents regarding touching a resident inappropriately. Allegation: Staff financially abused resident. The allegation alleges that the reporting party has witnessed other POA’s for patients at the facility accuse staff of financial theft. During interviews with Staff (S1- S3), they were asked if they or any staff have taken resident’s money, three (3) out of three (3) stated they have not taken money from any residents. Staff S1 stated when going shopping they have taken requests for specific items from residents, and they have given money for those items with a receipt provided. S2 stated there was an allegation of staff taking a resident’s money where the police and a social worker have been involved and that staff is no longer working here. During interviews with Residents (R1-R5), they were asked if staff has asked them for or taken money from them, five (5) out of five (5) stated they have not been asked for money by staff. Resident R3 stated they have asked S1 to pick up specific items while at the store and a receipt is provided so they know how much to pay. During file review LPA found that the facility does not handle any of the resident’s finances, either the resident or their representative handles their finances. Allegation: Staff falsified resident’s medical documentation. The allegation alleges that the caregiver has lied about resident’s results and does not document readings unless there is a complaint, and then makes numbers up. During the visit LPA observed R1 test their sugar with staff S1 next to them recording the numbers on a log sheet. During interviews with staff S1 stated they will get everything ready for R1 to test their sugar and they record the readings. During interviews with Resident R1 stated they test their sugar daily and that staff S1 is there to record the numbers. During document review, LPA observed that the resident’s levels are tested daily, and the log is kept on a corkboard in the dining room. During interviews with staff S1-S3, were asked if they have or know of a staff who have falsified records, three (3) out of three (3) stated they have not falsified records and do not have knowledge of staff falsifying records. During interviews with Residents (R1-R5), they were asked if they have any knowledge of staff falsifying records, five out of five stated they have no knowledge of staff falsifying records. Allegation: Staff are not bathing resident according to doctor’s orders The allegation alleges that the staff does not do any hygienic care (showering, toileting) and leaves clients on their own to attend to themselves. During interviews with Staff (S1- S3) three out of three stated the residents are bathed regularly. Interviews with Residents (R1-R5) five out of five stated they are assisted with bathing regularly. R1 and R4 stated they receive help when they shower twice a week. R3 and R5 stated they are assisted daily with showering. R2 stated they do not require assistance with the shower, and they shower daily. During file review, LPA did not see any orders from the resident’s physician regarding showering, and how often they should shower. Allegation: Direct care staff are not being informed of residents’ needs. The allegation alleges that relief staff are not notified of client’s care and medical conditions. During interviews with staff S1-S3, were asked if they are informed of resident’s needs, three (3) out of three (3) stated that when there are changes in a resident’s care they are informed by the family, hospice nurse, new doctor’s orders, other staff, or the residents of these changes. During interviews with Residents R1-R5, were asked if their needs are met, five (5) out of five (5) stated their needs are met. During file review, LPA observed staff receive training regarding care for residents conducted on 02/21/23. Allegation: Staff are not able to communicate due to a language barrier. The allegation alleges that staff are brought from another country who do not speak the language. During facility visits, LPA did not have any issues communicating with the staff. During interviews with Staff (S1-S3), were asked if they have any issues communicating with residents, three (3) out of three (3) stated they have no issues communicating with residents. During interviews with Residents R1-R5, were asked if they have any issues communicating their needs to staff, five (5) out of five (5) stated they have not issues communicating with staff. Allegation: Staff did not provide adequate activities for residents The allegation alleges that they do not have or offer activities to residents. During interviews with staff (S1-S3), were asked if residents are provided with activities, three (3) out of three (3) stated activities are provided for residents, but not all the residents want to participate. S2 stated if residents don’t want to participate, they try to find something they want to do, one resident likes to listen to music, another dance, and another likes to talk politics and about what is happening in the world. During interviews with Residents (R1-R5), were asked if activities are provided, five (5) out of five (5) stated there are minimal activities provided. Residents (R3-R5) stated they would rather do their own thing. During facility inspection, LPA observed games, activities, and karaoke available for residents. Additionally, LPA observed three residents singing with staff. Allegation: Facility staff does not respond to communications from resident’s authorized representative. The allegation alleges that a resident’s representative has sent many text messages to the supervisor and caregiver about their concerns, and they were met with hostility in text messages from the caregiver. During interviews with Staff S1-S3, they were asked if they communicate and respond to resident’s authorized representatives, three (3) out of three (3) stated they communicate and respond to resident’s representatives. During interviews with Residents R1-R5, were asked if staff respond to their authorized representatives inquires, three (3) out of five (5) stated they believe staff respond to their authorized representatives inquires. Residents R3 and R4 stated they are self responsible. Allegation: Staff did not notice a change in residents’ condition. The allegation alleges that a resident called another resident’s POA to inform them their resident was felling confused. During interviews with Staff (S1-S3), were asked if they watch residents for a change of condition and report it to their authorized representative, three (3) out of three (3) stated they watch for changes in condition and if they observe any, they contact the residents responsible party and the Physician and if necessary, call 911. During interviews with residents R1-R5, were asked if they received medical assistance when needed, five (5) out of five (5) stated they receive medical assistance when needed. During record review, LPA reviewed resident’s file folders and observed documents from doctor and hospital visits. Unsubstantiated During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Staff, Rey Malit, and a copy of this report was provided. Allegation: Staff neglect has resulted in resident developing multiple infections. The allegation alleges that a resident has been in and out of the hospital due to infections for UTIs and bacterial infections. During record review, LPA observed hospital documents regarding R1 experiencing Urinary Retention causing UTIs. During interviews with Staff S1-S3, were asked if residents care needs are being neglected causing infections, three (3) out of three (3) stated the residents are not being neglected and their care needs are being met. During interviews with Residents (R1-R5), were asked if their care needs are being neglected resulting in infections, five (5) out of five (5) stated their care needs are being met. Unsubstantiated During the course of the investigation, LPA was unable to find evidence to support the allegation. Although the allegation may have happened or is valid, there is no preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated. An exit interview was conducted with Staff, Rey Malit, and a copy of this report was provided.the state’s words, verbatim · CDSS document, May 6, 2024 · control 11-AS-20230626162504

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555 · Plan of correction due date: May 20, 2024

87555 General Food Service Requirements (b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident’s physician as a medical necessity shall be provided. This was not met based on: LPA reviewed physician’s orders for R1, R2, and R5, and found they required a special diet of low sodium, low carbohydrates, and low sugar and during interviews with R2 and R5 stated they are served item that do not meet the modified diet prescribed by physician. This poses a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 6, 2024

Plan of correction: Licensee aggrees to review Physicians Reports of residents, train staff on resident special diets. Have staff sign that they have been trained on residents special diet and fax to 424-544-1017 att LPA Gibbs by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465 · Plan of correction due date: May 20, 2024

87465Incidental Medical and Dental Care (c) if the resident’s physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) a record of each dose is maintained in the resident’s record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident’s response. This was not met based on: Record review of Resident R1s Physicians report and Centrally stored medications has 2 PNR medications and there is no documentation of R1 receiving thier PRN. This poses a health and safety risk to residents in care.the state’s words, verbatim · CDSS document, May 6, 2024

Plan of correction: Licensee shall ensure medications are administered according to PCP orders and that staff a trained on administering medications. The facilty will conduct a training on medications with staff. Proof of correction receipt must be sent to by fax to 424-544-1016 att Gibbs by POC date.

Type of visit: Case Management - Annual Continuation

On 12/12/23, Licensing Program Analyst (LPA), Wendy Gibbs, conducted an unannounced annual continuation visit to complete file reviews and medication review. LPA met with Caregiver, James Okeuhie, and explained the purpose of todays visit. During the time of visit there were four (4) residents present. Safety LPA observed smoke and carbon monoxide detectors to be operable. The last emergency drill was conducted on 09/23/23. LPA observed a fully charged fire extinguisher last serviced on 02/10/23. LPA observed a fully stocked First Aid Kit with a manual. LPA observed all required signs posted within the facility. Medications LPA observed Centrally Stored Medications secured in a locked cabinet in the kitchen and are inaccessible to residents. LPA reviewed Centrally Stored Medications for three residents and the Medication Administration Record (MAR) for those residents. LPA found that medications administered is consistent with documented records. Files/Interviews LPA reviewed resident files and observed the following documents missing from Resident R1’s file a Physicians Report (Medical Assessment) with a Tuberculosis (TB) test. LPA observed Resident’s R2-R4 files had the required documents. Interviews with Resident (R1-R4) four out of four stated their needs are met and they are cared for by staff. LPA reviewed Staff (S1-S3) file and found they contained the required documents, certification, and training. LPA interviewed Staff and they were able to answer questions regarding resident care, policy, procedure, and personal rights. LPA reviewed and received a copy of the facilities Liability Insurance which expires on 08/19/24. Infection Control During today’s visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and residents, sanitizing stations in common areas and restrooms. LPA observed required infection control signs posted throughout the facility. LPA observed a 30-day supply of PPEs stored in the closet. During today visit, per Title 22, two deficiencies were cited, please see attached LIC809-D An exit interview was conducted with Caregiver, James Okeuhie, and a copy of this report will be provided.the state’s words, verbatim · CDSS document, Dec 13, 2023

Type of visit: Required - 1 Year

On 10/20/23, Licensing Program Analyst (LPA), Wendy Gibbs conducted an unannounced annual visit using the full CAREs tool. LPA met with Caregiver, James Okeuhie, and explained the purpose of today’s visit. The facility is licensed to serve clients aged 60 and over, six non-ambulatory. They have an approved Hospice Waiver for six residents. There are currently 4 residents residing at the facility. Physical Plant/Structure The facility is a single-story structure located in a residential neighborhood. It consists of the following: three (3) bedrooms, 2 bathrooms, living room, kitchen, dining room, family room, garage, and a shaded area. LPA toured the inside and outside grounds of the facility with staff. All walkways on the side of the facility were clean, clear, and free of obstruction, debris, and hazards. There were no bodies of water observed. Bedrooms All bedrooms were inspected. All rooms have the required furniture including a bed(s), dresser(s), nightstand(s), chair(s), and storage space for residents’ personal belongings. All beds were observed to have the required linens including a mattress cover, fitted sheets, blanket, comforter, and pillows. LPA observed an ample supply of bed linens in a hall cupboard that were in good repair. All bedrooms were observed to have ample lighting. Bathrooms LPA inspected all bathrooms. Bathrooms were found to be within Title 22 regulations and were clean and operational. All bathrooms had secured handrails, nonskid mats, and a shower chair. LPA observed an ample supply of hygiene products and towels stored in a cupboard in the hall. The water temperature measured 118.3 and 119.2-degrees Fahrenheit. Kitchen LPA inspected the kitchen and found it to be clean and sanitary. All appliances were tested and are in good working condition. LPA observed an ample supply of cutleries, pots, and pans in good repair. LPA observed a 3-day supply of perishable foods and a 7-day supply of nonperishable foods. All food was properly labeled and stored. The water temperature measured 119.8-degrees Fahrenheit. All sharps were observed in a locked drawer in the kitchen and are inaccessible to residents. LPA observed all cleaning products secured in a locked cabinet under the sink and are inaccessible to residents. Common Rooms LPA inspected all common rooms. LPA observed two couches and activities in the family room for resident use. The living room has 5 recliners for residents. LPA observed a screened fireplace that is inaccessible to residents. The dining room has a large table and chairs to accommodate all residents. LPA will return to complete file review and medication review. An exit interview was conducted with Caregiver, James Okeuhie, and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 20, 2023

Type of visit: Case Management - Deficiencies

On 09/29/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a case management inspection visit at this facility. LPA met with House Manager Lucy A. Dezell and explained the purpose of the visit. During an investigation visit on 09/29/23 associated with complaint #11-AS-20230911101639, LPA, was informed that hospice file records for resident #1 (R1) were not available. LPA was informed by administrator Virginia Asis that (R1) was no longer a resident and was uncertain of the date when (R1) was discharged and had to confirm with the business office. The facility did not have discharge paperwork available nor hospice file and Medication Administration Records (MAR) for all residents. The facility did not have available during the investigation visit on 09/14/23 and 09/28/23 a Personnel Report LIC 500 was not provided. Based on the information provided by the administrator, the facility violates the California Code of Regulations (Title 22, Division 6, Chapter 8), deficiencies were observed, and citations were issued (ref. LIC 9099-D). An exit interview was conducted and a copy of the Evaluation Report and Appeal Rights were provided to Lucy Denzell.the state’s words, verbatim · CDSS document, Sep 29, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 8706(a) · Plan of correction due date: Oct 10, 2023

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff. This requirement is not met as evidence by: Based on observation and interview, Licensee failed to provide resident records for (R1) hospice records and Medicaiton Administration Record during visits. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: The licensee will ensure records for all residents are current and maintained for each resident in the facility and available to CCL during visits. LIcensee will obtain copies of hospice records and (MAR) for (R1). Proof of correction must be sent by due date 10/10/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87405(1)(2) · Plan of correction due date: Oct 10, 2023

87405 Administrator - Qualifications and Duties (b) The administrator of a facility.. shall have the responsibility and authority to carry out the policies... (1) Knowledge of the requirements for providing care and supervision... (2) Knowledge of and ability to conform to the applicable laws, rules, and regulations This requirement was not met as evidenced by: Based on observation record and interviews, the Administrator failed to adhere to Title 22 regulations, resulting to multiple deficiencies cited. This violation poses/posed a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: Licensee shall read Title 22, Section 87405 “Administrator - Qualifications and Duties” and send a written statement to CCLD that you have read and understand this section. This plan is due to CCLD/El Segundo ASC Office by POC date of 10/10/23.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(e) · Plan of correction due date: Oct 10, 2023

87412 Personnel Records (e) In all cases, personnel records shall demonstrate adequate staff coverage necessary for facility operation by documenting the hours actually worked. This requirement is not met as evidence by: Based on observation and interview, Licensee failed to provide personnel report LIC 500 during visits. Uncertain of adequate staff coverage. This poses a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 29, 2023

Plan of correction: The licensee will ensure records for all residents are current and maintained for each resident in the facility and available to CCL during visits. LIcensee will obtain copies LIC 500. Proof of correction must be sent by due date 10/10/23. This citation was correction during visit. A copy of LIC 500 provided.

Allegation investigated: Staff are not ensuring that resident receives medications as prescribed by their physician.

On 09/28/23, Licensing Program Analyst (LPA) Ernand Dabuet conducted a subsequent complaint visit. LPA was greeted by caregiver Allan Gloriani. Gloriani contacted Virgina Asis who later was present during the visit. LPA explained the purpose of today's visit is gather information for the allegations mentioned above. The investigation consisted of the following: LPA obtained copies of the roster for residents and staff. Service records for resident #1 (R1), and other pertinent documents associated with this complaint. Interviews with staff #1-#3 (S1-S3), residents #2-#5 (R2-R5), and witnesses #1 - 3 (W1-W3). A tour of the physical plant was conducted. Evaluation Report continues LIC 9099-C Substantiated INVESTIGATION REVEALED THE FOLLOWING: Allegation #6: Staff are not ensuring that resident receives medications as prescribed by their physician. The details of the complaint alleged that resident #1 (R1) may not be receiving medications as prescribed by the physician. The complainant reported due to (R1's) health condition it is suspected the doctor's prescribed medication orders are not being followed by staff. Service records revealed (R1) was admitted at Santa Fe Home Care II on 08/23/22 and was discharged on 09/18/23 according to administrator staff #1 (S1). (R1) was on hospice care and was being provided hospice care services twice a week. Pacific Post Acute Medical Records (dated: 08/23/22) listed (R1) was on (12) prescription medications. An interview between 10:01 am - 10:49 am with (2) out of (2) staff #2-#3 (S2-S3) confirmed that not knowing what a Medication Administrator Record (MAR) is for (R1). (S2) admitted that no medications were documented when administered to residents. (S2) confirmed that hospice did not assist with (R1's) medications and that only the staff at Santa Fe Home assisted. An interview with (S1) confirmed that staff assisted with medications for the residents and that the facility has a (MAR) on record but was unable to produce the records for the Department for review. The Department interviewed residents between 09:02 am - 12:00 pm (2) out (5) residents handled their medications residents #2 and #5 (R2 and R5). Three residents required assistance with medications residents #1, #3, and #4 (R1, R3, and R4). Physician's Report for (R1) (dated 08/05/22) indicated (R1) is not able to manage own prescription medications or able to administer own PRN medications. An interview with (R1) was conducted on 09/15/23, however, due to (R1's) health condition (R1) was not able to hold a conversation. The facility was not able to produce evidence of hospice records, resident's progress notes or (MAR) when requested. Based on the information gathered, there is sufficient evidence to support the allegation mentioned above. Based on observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California Code of Regulations, Title 22, Division 6, and Chapter 8 are being cited on the attached LIC 9099-D. An exit interview was conducted with Virginia Asis, Administrator, and a hard copy of the report along with appeal rights.the state’s words, verbatim · CDSS document, Sep 28, 2023 · control 11-AS-20230911101639

From the deficiency page — Deficiency type: Type A · Section cited: CCR 98465(c)(2) · Plan of correction due date: Sep 29, 2023

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need .. medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist...(2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidence by: Based on interviews, the licensee did not comply with this section. Licensee did not have evidence to show proof that prescribed medications or PRN for (R1,R3 & R4) were administered PCP orders. This poses an immediate health, safety or personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Sep 28, 2023

Plan of correction: Licensee shall ensure medications are administered according to PCP orders with proof of documentation. Licensee will obtain a copy of documentation noting medications were disbursed properly per PCP orders. Proof of correction receipt must be sent to by fax to 323-981-1782 attn: LPA Dabuet by 09/29/23. This was corrected during Case Management visit on 09/29/30.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Nov 10, 2023

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2)To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidence by: Based on interviews, the licensee did not comply with this section. Staff assisted with medications for residents without knowledge of documenting PRN or prescribed medications. Residents are not provided a safe environment. This a potential health, safety or personal rights risks to persons in care.the state’s words, verbatim · CDSS document, Sep 28, 2023

Plan of correction: Licensee shall ensure medications are administered according to PCP orders and that staff a trained on administering medications. The facilty will conduct a training on medications with staff. Proof of correction receipt must be sent to by fax to 323-981-1782 attn: LPA Dabuet by 10/10/23.

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.