<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602274
Report Date: 06/20/2026
Date Signed: 06/20/2026 12:05:10 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/10/2025 and conducted by Evaluator Regina Cloyd
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20250710130802
FACILITY NAME:SANTA FE HOME CARE IVFACILITY NUMBER:
198602274
ADMINISTRATOR:GRADNEY, ANGELIQUEFACILITY TYPE:
740
ADDRESS:5010 TORRANCE BLVDTELEPHONE:
(310) 316-0001
CITY:TORRANCESTATE: CAZIP CODE:
90503
CAPACITY:6CENSUS: 5DATE:
06/20/2026
UNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Nelson OrtegaTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff neglect.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 06/20/2026, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced subsequent complaint investigation visit to deliver an updated complaint investigation report for the allegation listed above. This report supersedes the report dated 01/14/2026. This report has been updated due to provide additional information. This report does not change the findings, the findings remain as “Substantiated”. LPA met with Nelson, and the purpose of the visit was explained.

The investigation consisted of the following:
On 07/11/2025, a facility tour was conducted, and records were gathered. Facility records were gathered which consisted of Resident Roster dated 06/01/2025 and Personnel Report dated 07/01/2025. Resident 1’s (R1) records were gathered which consisted of Admission Agreement dated 03/11/2020; Physicians Report dated 05/24/2024; Appraisal/Needs and Services Plan dated 05/12/2024; Resident Appraisal dated 03/21/2023; Identification and Emergency Information dated 03/22/2020; Hospital Records dated 07/07/2025 to 07/14/2025; and other pertinent records were provided. Continue to LIC9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 11-AS-20250710130802
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245
FACILITY NAME: SANTA FE HOME CARE IV
FACILITY NUMBER: 198602274
VISIT DATE: 06/20/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
On 07/23/2025, Staff 1 (S1) to Staff 3 (S3) were interviewed. On 09/26/2025, Staff 4 (S4) and Witness 1 (W1) were interviewed. On 10/14/2025, R1 was interviewed. On 10/15/2025, W1 and Witness 2 (W2) were interviewed. On 01/07/2026, S1 to S3 and Resident 2 (R2) to Resident 5 (R5) were interviewed.

Investigation revealed the following:

Allegation: “Staff neglect”, it is being alleged that staff neglected R1. Record reviews revealed the following: R1’s records revealed that the licensee did not: document changes in R1’s condition; There were no records of updated yearly Physicians Reports; and Appraisal/Needs and Services Plans. R1’s Admission Agreement dated 03/11/2020 indicated that R1 will receive “B. Basic services at a minimum include: 1. Continuous care and supervision…9. Assistance with personal activities of daily living as follows: toileting, mobility tasks, and other personal care needs”. R1’s Appraisal/Needs and Services Plan (ANS) dated 03/21/2024 does not have R1’s signature nor the resident’s authorized representative signatures; and does not mention incontinence care nor dietary needs. Physicians Report dated 05/24/2024 indicated that R1 was diagnosed/assessed with the following: dementia; motor impairment/paralysis; confused/disoriented; not able to leave the facility unassisted; not able to provide own self-care such as grooming, care for own toileting needs, etc.; non-ambulatory based on both physical and mental condition; weighted 129 pounds; and has a history of bacterial infections. Hospital Records dated 07/07/2026 to 07/14/2026 revealed that R1 was diagnosed with Malnutrition, Urinary Tract Infection, altered mental status, and required medical interventions. Personnel Report dated 07/01/2025 indicates that there were no staff on duty Monday to Sunday from 9:00 PM to 7:00 AM. Interviews revealed the following: On 07/23/2025, S1 indicated that they observed R1’s health on a decline. On 01/07/2026 staff S1 to S3, indicated that R1 would only receive incontinence care before 9:00 PM and after 7:00 AM.

Based on records reviewed and interviews conducted the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

An exit interview was conducted, and a plan of correction was developed. A copy of this report and appeal rights were provided to Nelson.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2