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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191504447
Report Date: 05/11/2021
Date Signed: 05/11/2021 04:19:32 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/03/2021 and conducted by Evaluator Angelica Rea
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20210503141802
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
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Joshua NovogradTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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Staff are unable to maintain social distance while working in kitchen.
INVESTIGATION FINDINGS:
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Licensing Program Analysts Angelica Rea and Nune Margaryan conducted an unannounced complaint visit in response to the above allegation. LPA's met with Administrator, Joshua Novograd who assisted with today's visit.

Regarding the allegation that Staff are unable to maintain social distance while working in kitchen. The investigation consisted of interview(s) with Administrator, Staff #1- Staff #4, and review of Staff files. The investigation revealed that on about 5/3/21, the Skilled nursing facility (SNF) which is directly next door to Santa Anita Retirement Center had to shut down it's kitchen due to a Public Health violation. Administrator and staff interviewed stated that all kitchen staff from the SNF were working in the Santa Anita Retirement Center kitchen for approximately 1 weeks time. During this time there were approximately 15 extra staff working in the RCFE kitchen which prevented kitchen staff from maintaining social distance. Additionally, the facility did not report this incident to Community Care Licensing as required, Facility will be cited accordingly.

Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 28-AS-20210503141802
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 05/11/2021
NARRATIVE
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Based on LPAs observations and interviews which were conducted record review(s), 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 are being cited on the attached LIC 9099D.

Exit interview conducted with Administrator. Copy of report, and Appeal Rights provided.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20210503141802
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
05/13/2021
Section Cited
HSC
1569.50(a)(3)
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(a) The department may deny an application for a license or may suspend or revoke a license issued under this chapter upon any of the following grounds and in the manner provided in this chapter:(3) Conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility or the people of the State of California.
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Administrator will ensure that facility is following California Dept of Public health and CCLD requirements. Administrator will provide a written statement stating that he will comply with CDSS requirements and regulations and wil maintain a safe and healthful environment for residents and staff.
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This requirement is not being met as evidenced by: LPA's were informed that approximately 15 staff from skilled nursing facility were working in RCFE kitchen, which prevented kitchen staff from maintaining social distance. This poses a health and safety risk.
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Type B
05/13/2021
Section Cited
CCR
87211(a)(1)(D)
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Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: 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.
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Administrator will ensure that he reports any incidents which may threaten the welfare, safety or health of any resident. Administrator will review Title 22 regulation 87211, and will send a written statement stating that he understands and will comply with the regulation.
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This requirement is not being met as evidenced by: Administrator did not report the incident to Community Care Licensing as required. This poses a health and safety risk to residents in care.
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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
LIC9099 (FAS) - (06/04)
Page: 3 of 3