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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191504447
Report Date: 05/11/2021
Date Signed: 05/11/2021 04:21:02 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SANTA ANITA RETIREMENT CENTERFACILITY NUMBER:
191504447
ADMINISTRATOR:NAFTALI BURSTEINFACILITY TYPE:
740
ADDRESS:5600 GRACEWOOD AVE. #84TELEPHONE:
(626) 442-8410
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY:150CENSUS: 53DATE:
05/11/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Joshua Novograd TIME COMPLETED:
02:30 PM
NARRATIVE
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LPA's Angelica Rea and Nune Margaryan observed during investigation for complaint #28-AS-20210503141802, that Staff #1 and Staff #2 were not associated to work at the facility.

LPA's requested to review Staff files, and Administrator stated that Staff #1 and Staff #2 files were located at the Skilled Nursing Facility. Administrator brought files from SNF for LPA's to review.

Administrator stated that Staff #1 and Staff #2 are fingerprint cleared, however, there was no documentation observed in Staff files to indicate that they have been transferred and associated to the facility.

Facility will be cited, and civil penalties will be issued.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SANTA ANITA RETIREMENT CENTER
FACILITY NUMBER: 191504447
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/18/2021
Section Cited

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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)
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This requirement is not met as evidenced by:
LPA's observed Staff #1 and Staff #2 are not associated to
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica ReaTELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:
DATE: 05/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/11/2021
LIC809 (FAS) - (06/04)
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