Santa Fe Home Care III

Type of visit: Case Management - Other

On 08/14/2025, Licensing Program Analyst (LPA) Jose Calderon conducted a Case Management visit at this facility. LPA met with designated administrator Trisha DeOcampo who allowed entry in this facility. LPA informed DeOcampo the purpose of the visit is to conduct a health and safety check and inspect the physical plant. Investigation revealed the following: LPA conducted a tour of the entire facility. During the inspection, LPA observed the following: (4) bedrooms (2) bathroom, kitchen, living room, den, patio, and garage LPA observed all (6) residents residing at this home requiring assistance with assisted daily living (ADLs) This property address is licensed to Santa Fe Home III #198602162. LPA Calderon requested a copy of the LIC500 and inspected the food supply. No deficiencies cited during today's visit. An exit interview was conducted with Trisha DeOcampo, and a copy of the report was provided.the state’s words, verbatim · CDSS document, Aug 14, 2025

Type of visit: Case Management - Health Checks

On 08/22/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a Case Management visit at this facility. LPA met with designated administrator Evangeline Agatep who allowed for the entry in this facility. LPA informed Agatep the purpose of the visit is to conduct a health and safety check. Investigation revealed the following: LPA conducted a tour of the entire facility. During the inspection, LPA observed the following: (4) bedrooms (2) bathroom, kitchen, living room, den, patio, and garage LPA observed all (5) residents residing at this home requiring assistance with assisted daily living (ADLs) This property address is licensed to Santa Fe Home III #198602162. According to Residential Lease Agreement (dated: 05/24/24), Santa Fe Home III lost control of the property effective 06/04/24. The Residential Lease Agreement contract had Ace Elderly Homes, Inc. under contract effective 06/05/24. Ace Elderly Homes, Inc. submitted an Application for A Community Care Facility LIC 200 on 07/02/24 to Central Applications Bureau, which is still under consideration. Based on the Department’s observation and interviews conducted, the preponderance of evidence standard has been met, therefore the allegation of “Unlicensed Care is Being Provided" is found to be: "Substantiated". You are hereby issued a Notice of Operation in Violation of the Law letter. You are to cease operation or submit an application to the CCLD Senior Care Office on or before 09/06/24 or relocate the resident to a licensed assisted living facility. If you fail to: cease operation or relocate the resident a civil penalty will be assessed. Failure to comply will result in civil penalties of $200 per day until a completed application is submitted, operations cease, or written verification from a licensed mental health professional or residents are relocated. (Evaluation Report continues LIC 809-C) The operator was given a copy of the “Notice of Operation in Violation of Law" letter. Deficiency Cited: Health and Safety Code 1569.44. An exit interview was conducted with Evangeline Agatep, and a copy of the report and appeals rights were provided.the state’s words, verbatim · CDSS document, Aug 22, 2024

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.44(a) · Plan of correction due date: Sep 6, 2024

1569.44(a) Unlicensed residential care facility for the elderly; definition; operation without license prohibited; procedure upon discovery (a) A facility shall be deemed to be an "unlicensed residential care facility for the elderly" and "maintained and operated to provide residential care" if it is unlicensed and not exempt from the licensee, and any one of the following conditions is satisfied: This requirement is not met as evidence by: Based on interviews conducted and observation the operator is providing unlicensed care to R1-R5 who require elements of care and supervision. The facility is not licensed by CCLD. This poses a potential Health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 22, 2024

Plan of correction: Based on interviews conducted and observation the operator is providing unlicensed care to (R1-R5) who require elements of care and supervision. This poses an immediate Health and safety risk to residents in care. The unlicensed operator shall either cease operation of the unlicensed facility or operations ceased or submit an application to the licensing agency within 15 calendar days by 09/06/24. Failure to comply will result in civil penalties of $200 per day until a completed application is submitted,

Type of visit: Case Management - Deficiencies

On 08/22/24, Licensing Program Analyst (LPA) Ernand Dabuet conducted a Case Management visit at this facility. LPA met with designated administrator Evangeline Agatep who allowed for the entry in this facility. LPA informed Agatep the purpose of the visit is to conduct a health and safety check. LPA reviewed resident's service records and identified Resident #1 (R1) who is under hospice care is unable to self-care requires night supervision. (R1's) Physician's Report LIC 602-A indicated (R1) requires continuous bed care as (R1) is bladder and bowel impairment with dementia. According to Personnel Report LIC 500 night supervision is on-call basis. There is no regular staff assigned to night supervision shift after 11:00 pm. Based on observations, interviews, and record reviews, the preponderance of evidence standard has been met with California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099-D. Exit interview was conducted with Evangeline Agatap, and a hard copy of the report along with appeal rights.the state’s words, verbatim · CDSS document, Aug 22, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(4)(A) · Plan of correction due date: Sep 6, 2024

87705 Care of Persons with Dementia (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 evidence by: Based on interviews and record reviews, licensee did not have night supervision for dementia resident (R1). No staff on duty after 11pm. This violation poses a potential health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Aug 22, 2024

Plan of correction: Licensee will adhere to Title 22 87705 Regulations and ensure that at least one staff for NOC shift. Plan of correction must be sent to LPA by POC date via email: ernand.dabuet@dss.ca.gov

Type of visit: Required - 1 Year

On 08/08/2024 at 11:30 AM, Licensing Program Analyst LPA) Jose Calderon conducted an unannounced annual inspection visit at the Santa Fe Home Care III Facility. LPA Calderon was allowed entry into the facility by Administrator Evangeline Agatep. Administrator Evangeline Agatep asked infection control questions and took LPA Calderon temperature prior to entrance into the facility. The facility is licensed for six (6) non-ambulatory elderly adults ages 60 and over of which one (1) may be bedridden and have an approved hospice waiver for four (4). Currently, there are three (3) residents residing in the facility, between the age of 18 to 59 with cognitive issues. LPA Calderon explained to Administrator Evangeline Agatep, the purpose of the one-year Annual Inspection visit, and escorted LPA Calderon on a tour of the entire inside and outside facility grounds. As part of the inspection, LPA Calderon reviewed: Three (3) client service records, three (3) client medication records (MAR), three (3) staff records, and inspected the inside facility and outside grounds. LPA Calderon interviewed three (3) clients and three (3) staff members for visit. The facilities’ last fire drill was conducted on 08/05/2024. The one-story residential home consists of four (4) client bedrooms, two (2) client bathrooms, living room, dining room, kitchen, staff room, office area, attached garage with washer and dryer/ storage area, backyard with table and chairs. No weapons are stored in the premises. Kitchen was inspected and observed to be clean and operational. A two-day supply perishable and seven-day supply of non-perishable foods are present in the facility. Emergency Water Storage is in the garage and kitchen area. LPA Calderon observed that all facility rooms are clean and in good repair. A comfortable temperature was observed, and the facility has central air and heating. LPA Calderon observed the following during inspection of client’s rooms: mattresses are in good condition, adequate lighting present, plenty of dresser/closet space is present, and all bed linens present. All bedrooms contain furniture, lighting fixtures and personal storage space as required, all beds have the required amount of linen and mattress covers, LPA Calderon observed fully stocked closet with bedding, towels, and toiletries supplies. Bathroom fixtures are clean, in good repair, and working properly and contain the required nonskid mats and grab bars. LPA Calderon observed bathrooms were found to be within Title 22 regulation. Bathroom #1 hot water temperature properly measured at 110 degrees Fahrenheit, and bathroom #2 hot water temperature properly measured at 111 degrees Fahrenheit. Kitchen hot water temperature properly measured at 112 degrees Fahrenheit. Facility (2) Carbon Monoxide and (6) Smoke Detectors are batterie run and connected were tested and are working properly. The facility has no Fire Extinguishers in the facility. Fire Extinguishers were ordered on 8/5/2024. All exit doors in the facility have alarm systems. The facility has a working landline telephone. All toxins and knifes are locked/secured and inaccessible to clients. Medications are centrally stored and in a locked storage cabinet. Facility one (1) first aid kit is fully stocked with manuals was checked and in order. Outside grounds were toured and no bodies of water were observed. All Exits/ Walkways around the home were free of debris and hazards. Outside patio accessible to clients. Three (3) client files were reviewed and found to be complete. LPA Calderon reviewed three (3) resident medications (MAR) and they were all found to be administered according to doctor's orders. Three (3) staff files were checked and have the required documents. LPA Calderon noted the Administrator Evangeline Agatep Certification # 6021587740 expiration date of 11/08/2024 was valid at time of inspection. The facility does not handle client's money/cash resources and a Surety bond is not needed. Commercial General Liability Policy #RN70327041 policy period from 08/18/2023 to 08/18/2024 underwritten by Richmond National Insurance Company, coverage 1,000,000/3,000,000 is valid at time of inspection. Administrator Evangeline Agatep to email LPA Calderon a full copy of the commercial insurance policy including all endorsements no later than 08/23/2024. All the required documents are posted in the facility in a clearly visible area. During the visit, LPA observed the facility infection control practices. LPA observed screening protocols for visitors, staff, and clients, sanitizing stations (Located in common areas and restrooms). LPA observed staff and clients were NOT wearing face coverings. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). LPA Calderon advised the Administrator Evangeline Agatep to continuously monitor the Centers for Disease Control (CDC) website and Community Care Licensing Provider Informational Notices (PIN) for any updates relating to COVID-19 guidance. According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA Calderon did observe 2 deficiencie therefore TWO citations were issued at this time. Annual Licensing Fee is CURRENT $495.00 is owed on 08/25/2024, PIN 217993. An exit interview was conducted, and a copy of the Facility Evaluation Report was provided to Administrator Evangeline Agatep.the state’s words, verbatim · CDSS document, Aug 8, 2024

Allegation investigated: Resident’s personal belongings are missing.

On 12/22/2023, LPA Lourdes Montoya conducted a subsequent complaint visit at this facility to deliver the complaint findings of the above allegation. LPA met with Administrator Virginia Asis. LPA explained the purpose of today's visit. The investigations consisted of the following: On 12/21/2023, LPA toured the facility with Office Staff Rodolfo Lozada. LPA requested staff roster & resident roster, R1's service records and other pertinent records. LPA conducted interviews with three staff and two residents at the facility. One resident was sleeping and LPA was unable to obtain a statement. On 12/22/2023, LPA conducted a phone interview with one staff. REPORT CONTINUED IN LIC 9099-C Unsubstantiated Investigations Revealed the following: Allegation: Resident’s personal belongings are missing. Soc 341 indicates “The resident used to live at the facility, and approximately a month and a half ago resident moved out. Resident’s personal belongings are still at the facility. Multiple times the resident asked the facility about it, but they said they don’t have it. The resident believes the facility staff stole the resident’s personal belongings. It is alleged that resident’s personal belongings are missing. On 12/21/2023 at 1:00 pm – 3:00 pm, LPA Lourdes Montoya conducted interviews with staff and residents. LPA conducted a phone interview with one staff (S1), two staff (S2-S3) and two residents (R2-R3) at the facility. On 12/22/2023 at around 8:55 am, LPA conducted a phone interview with one former staff (S4). Interviews with two staff (S1-S2) revealed the facility was fumigated on March 2, 2023 and was reopened in April 29, 2023. R1 was transferred temporarily to another facility due to the temporary closure of the facility but R1 did not return to the facility. Interview with R1 revealed R1 left some shirts, blue jeans, shoes and other miscellaneous items at Santa Fe Home Care III and has not recovered them. Three staff (S1, S2 and S4) stated staff packed all R1’s personal belongings and were brought to the facility where R1 moved to. S1 and S2 stated they searched the facility for R1's belongings and brought some clothing and shoes to R1 but R1 denied they belonged to him. S1, S2 and S3 revealed R1 has been residing at the facility for a very long time and R1’s current personal belongings are not recorded and therefore it is unclear what specific items R1 are missing. S3 claimed S3 has no knowledge of R1’s personal belongings. LPA observed the facility did not maintain an inventory list to safeguard R1's personal property but it is unclear that R1 had lost personal belongings. Based on the records review and interviews conducted, the Department did not find enough evidence to support the allegation mentioned in this complaint. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated. Deficiencies were cited during this visit. An exit interview was conducted with and a copy of the report was provided to Administrator Virginia Asis.the state’s words, verbatim · CDSS document, Dec 22, 2023 · control 11-AS-20231219134346

Type of visit: Case Management - Deficiencies

On 12/22/2023, LPA Lourdes Montoya conducted a case management - deficiency visit at this facility during an unrelated complaint visit. LPA met with Administrator Virginia Asis. LPA explained the purpose of today's visit. On 12/21/2023 during an investigation of an unrelated complaint, LPA Montoya observed while conducting records review that R1's Safeguard for personal belongings/valuable is not current and complete. Based on LPA's interviews with S1, S2 and S4, the facility was temporarily closed due to cockroach infestation. S1 and S2 stated the facility was closed on March 2, 2023 for fumigation and was reopened on April 29, 2023. LPA observed the facility failed to report to CCLD the temporary closure of the facility. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Exit interview conducted. Appeal rights and a copy of this report was provided to Administrator Virginia Asis.the state’s words, verbatim · CDSS document, Dec 22, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(b)(16) · Plan of correction due date: Dec 29, 2023

87506 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 was not met as evidenced by: On 12/21/2023 during an investigation of an unrelated complaint, LPA Montoya observed while conducting records review that R1's Safeguard for personal belongings/valuable is not current and complete. This poses a potential risk to health, safety, and personal rights of residents in care.the state’s words, verbatim · CDSS document, Dec 22, 2023

Plan of correction: Licensee shall ensure all residents have complete and current Safeguards for Personal/Valuable forms. Licensee shall update R1's LIC621 and submit a copy to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date 12/29/23.

From the deficiency page — Deficiency type: Type B · Section cited: ILS87211(a)(1)(D) · Plan of correction due date: Dec 29, 2023

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement was not met as evidenced by: Based on LPA's interviews with S1, S2 and S4, the facility was temporarily closed due to cockroach infestation. S1 and S2 stated the facility was closed on March 2, 2023 for fumigation and was reopened on April 29, 2023. LPA observed the facility failed to report the temporary closure of the facility. This poses a potential risk to health, safety, and personal rights of residents in care.the state’s words, verbatim · CDSS document, Dec 22, 2023

Plan of correction: Administator shall review the section cited herein and shall self-certify understanding and compliance to this regulation. POC shall be submitted to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.

Type of visit: Case Management - Deficiencies

On 12/21/2023, LPA Lourdes Montoya conducted a case management - deficiency visit at this facility during an unrelated complaint visit. LPA met with Staff Laxuqsha Bailey. LPA explained the purpose of today's visit. Office staff Rodolfo Lozada arrived later and assisted LPA with the visit. At around 1:55 PM, LPA met with a caregiver (S1) who is not associated with the facility. S1 explained S1 normally works at another facility owned by the same licensee however, today, S1 was called to assist and supervise three residents at Santa Fe Home Care III. S1 stated S1 began working today at 7:20 AM. Based on LPA's interview with Lozada, S1 is fingerprint clear and associated to another facility but not associated to Santa Fe Home Care III. Lozada confirmed S1 commenced working at this facility today. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Civil penalties assessed. Exit interview conducted. Appeal rights and a copy of this report was provided to Office Staff Rodolfo Lozada.the state’s words, verbatim · CDSS document, Dec 21, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(2) · Plan of correction due date: Dec 22, 2023

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement was not met as evidence by: On 12/21/2023 at around 1:55 PM, LPA met with a caregiver (S1) who is not associated with the facility. Based on LPA's interview with Office Staff Lozada, S1 stated is fingerprint clear and associated to another facility but not associated to Santa Fe Home Care III. Lozada confirmed S1 commenced working at this facility today. This poses an immediate risk to health, safety and/or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Dec 21, 2023

Plan of correction: Lozada provided LPA with S1's background clearance, Criminal Background Clearance Transfer Request and ID and Personnel Record. This deficiency has been corrected during today's visit.