SANTA FE HOME CARE IV

Official classification

Type B

Official code

87211(a)(1)(D)

Regulation authority

CCR

What the official deficiency says

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 is not met as evidenced by: Based on records reviewed the licensee did not comply with the section cited above in not submitting Unusual Incident/Injury Reports to the department for R1’s hospitalization on 7/7/2025 to 7/14/2025 which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The house manager has agreed to train staff on reporting requierments. Email trainings to Socorro.Leandro@dss.ca.gov

Deadline recorded: Aug 24, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions. (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met as evidenced by: Based on records reviewed the licensee did not have a written order from a physician for R1’s bed rails and Hoyer lift which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The house manager has agreed to create a plan to maintain a written order for postural supports for all residents in care. Email plan to Socorro.Leandro@dss.ca.gov

Deadline recorded: Aug 24, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(h)(1-3)

Regulation authority

CCR

What the official deficiency says

Reappraisals (h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record. (2) Documentation of a resident's refusal to receive an annual routine visit, or if applicable, their representative's refusal on their behalf, shall be added to the resident's record. (3) If a resident refuses to receive an annual routine visit, or if applicable, their representative refuses an annual routine visit on their behalf, but later agrees to one, documentation of the annual routine visit shall be added to the resident’s record. This requirement is not met as evidenced by: Based on records reviewed the licensee did not comply with the section cited above in not having a record of R1’s annual routine medical visit / refusal which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The house manager has agreed to create a plan to ensure that all residents have a documented annual routine medical visit / refusal. Email plan to Socorro.Leandro@dss.ca.gov

Deadline recorded: Aug 24, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87463(a)

Regulation authority

CCR

What the official deficiency says

Reappraisals (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by: Based on records reviewed the licensee did not comply with the section cited above in not having a record of R1’s yearly appraisal which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The house manager has agreed to create a plan to ensure that all residents have an updated reappraisal once every 12 months and/or when staff observe a change of condition, whichever occurs first. Email plan to Socorro.Leandro@dss.ca.gov

Deadline recorded: Aug 24, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement is not met as evidenced by: Based on records reviewed and interviews conducted, the licensee did not document R1’s change of condition and did not bring it to the attention of R1’s medical provider and responsible person which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The house manager has agreed to create a plan to document residents change of condition and bring it to the attention of residents medical provider(s) and reponsible person(s). Email plan to Socorro.Leandro@dss.ca.gov

Deadline recorded: Aug 24, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87555(b)(27)

Regulation authority

CCR

What the official deficiency says

General Food Service Requirements (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by: Based on observations, the licensee did not maintain the kitchen areas free of vermin/insects which posed/poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The house manager has agreed to increase the number of times the facility gets fumigated and deep clean the kitchen to decrease the amount of vermin in the facility and create a plan to eliminate all vermin from the kitchen areas and maintain the facility free of vermin. Email fumigation contract to come to the facility regularly, email pictures of deep cleaned kitchen, and plan to maintain the facility free of vermin to Socorro.Leandro@dss.ca.gov

Deadline recorded: Aug 18, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Based on record review, R1 required continuous care and supervision, and the licensee did not have staff working between 9 PM to 7 AM thus, staff did not provide R1 with continuous care and supervision, which posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

The staff has agreed to re-read CCR87411(a). For residents that quire continuous care and supervision the staff has agreed to provide residents with 24-hour staff continuously working. The licensee will create a plan to provide residents with continuous care and supervision for residents that require it (based on physician’s reports, care plans, admission agreements, observations, etc.). The licensee will email updated LIC500 and plan to Ulysses.Coronel@dss.ca.gov & Socorro.Leandro@dss.ca.gov

Deadline recorded: Jan 15, 2026. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87411(a)

Regulation authority

CCR

What the official deficiency says

(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above in the facility not having continous night staff, according to records review facility residents requiere continous care and supervision, which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/12/2025 Plan of Correction The Administrator has agreed to re-read residents physicians reports, care plans, and CCR87411(a). The Administrator has agreed to provide residents with continous 24 hour care. The licensee will email LIC500 to Ulysses.Coronel@dss.ca.gov & Socorro.Leandro@dss.ca.gov

Official classification

Type B

Official code

87465(c)(3)

Regulation authority

CCR

What the official deficiency says

(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 requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above in not documenting the residents' response to the PRN medication which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/30/2025 Plan of Correction The Administrator has agreed to re-read CCR 87465. The Administrator has agreed to retrain staff on how to provide residents with PRN medication and document PRN medication. Email proof of correction to Socorro.Leandro@dss.ca.gov

Official classification

Type B

Official code

87628(a)

Regulation authority

CCR

What the official deficiency says

(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above, according to staff Resident 3 (R3) injected themselves through their assistance (according to R3's physicians report they are unable to inject themselves) which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 12/10/2025 Plan of Correction The facility Administrator solved this issue. On 12/05/2025, R3 was prescribed insulin pills. R3 is currently taking insulin pills.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

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: 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.

Official plan of correction

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. Proof of correction will be emailed to Socorro.Leandro@dss.ca.gov

Deadline recorded: Aug 30, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87303(b)(2)

Regulation authority

CCR

What the official deficiency says

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: 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.

Official plan of correction

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. 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

Deadline recorded: Aug 30, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 10/04/2024 Plan of Correction 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***

Official classification

Type A

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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 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.

Official plan of correction

POC Due Date: 10/04/2024 Plan of Correction 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

Official classification

Type B

Official code

87608(a)(5)(B)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 10/17/2024 Plan of Correction 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

Official classification

Type B

Official code

87705(c)(4)(A)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 10/17/2024 Plan of Correction 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

Official classification

Type B

Official code

87303(c)

Regulation authority

CCR

What the official deficiency says

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by: Deficient Practice Statement 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.

Official plan of correction

POC Due Date: 10/17/2024 Plan of Correction 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

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(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 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.

Official plan of correction

POC Due Date: 10/17/2024 Plan of Correction 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

Official classification

Type B

Official code

1569.626(a)(1)

Regulation authority

HSC

What the official deficiency says

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 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.

Official plan of correction

POC Due Date: 10/17/2024 Plan of Correction 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

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

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 Based on observation the licensee did not comply with the section cited above in having the bathroom ceiling in disrepair which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/16/2024 Plan of Correction Licensee will ensure facility is in good repair at all times. Also, Licensee will fix the bathroom ceiling, when done licensee will submitt proof of correction to LPA via email before POC due date.

Official classification

Type B

Official code

1569.618(a)

Regulation authority

HSC

What the official deficiency says

(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interviews the licensee did not comply with the section cited above in having an administrator designee promptly available at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/09/2024 Plan of Correction Licensee will ensure administrator designee is available at all times at the facility. In addition, licensee will ensure designee is promptly available at the facility during regular business hours and will choose another designee.

Official classification

Type B

Official code

87411(c)(1)

Regulation authority

CCR

What the official deficiency says

(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 Based on observation record review, the licensee did not comply with the section cited above in having expired CPR card in staff files which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/09/2024 Plan of Correction Licensee will ensure all staff CPR cards are updated. In addition, licensee will submitt the new CPR cards to LPA before POC due date via email.

Official classification

Type B

Official code

87506(b)(15)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation record review, the licensee did not comply with the section cited above in having resident's admission agreement form other home and not the current one which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/09/2024 Plan of Correction Licensee will ensure all residents have a current admission agreement. In addition, licensee will submitt corrected admission agreement to LPA via email before POC due date.

Official classification

Type B

Official code

87506(b)(16)

Regulation authority

CCR

What the official deficiency says

(b) Each resident's record shall contain at least the following information: (16) Records of resident's cash resources as specified in Section 87217, Safeguards for Resident Cash, Personal Property, and Valuables. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview record review, the licensee did not comply with the section cited above in having the SPV form done on the residents files which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/09/2024 Plan of Correction Licensee will ensure all residents have their SPV forms on files. In addition, licensee will submitt proof of correction to LPA via email before POC due date.

Official classification

Type B

Official code

1569.695(c)

Regulation authority

HSC

What the official deficiency says

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview and record review, the licensee did not comply with the section cited above in not having proof of quaterly disaster drills when requested by LPA which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 01/09/2024 Plan of Correction Licensee will ensure facility disaster drills are available at the facility at all time. In addition, licensee will submitt proof of facility disaster drill to LPA via email before POC due date.

Official classification

Type A

Official code

87303(e)(2)

Regulation authority

CCR

What the official deficiency says

(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 that 105 degree F and not more than 120 degree Fahrenheit. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. LPA Montoya observed the water temperature in bathroom #1 next to resident bedrooms #1 & #2 is 151.1 degree F and the water temperature in bathroom #2 next to resident bedroom #3 is 126.9. degree F. This poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 08/23/2022 Plan of Correction The administrator shall ensure the water temperature is always within compliance. The administrator shall test and record the water temperature every two hours within the next 24 hours and submit the records of the temperature to CCLD via email to lourdes.montoya@dss.ca.gov by the POC due date.