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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191504447
Report Date: 04/22/2022
Date Signed: 04/22/2022 09:23:04 AM


Document Has Been Signed on 04/22/2022 09:23 AM - It Cannot Be Edited

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:GEMMA DEOSOFACILITY TYPE:
740
ADDRESS:5600 GRACEWOOD AVE. #84TELEPHONE:
(626) 442-8410
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY:150CENSUS: DATE:
04/22/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:05 AM
MET WITH:Gemma G DesosTIME COMPLETED:
09:35 AM
NARRATIVE
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Licensing Program Analyst (LPA) Christine Wong conducted a case management visit t to the facility to ascertain information pertaining to the Administrator-initiated Incident Report /SOC341 (occurred on 04/12/22). LPA met with Assistant Administrator William Woods who allowed entry into the facility and was later met by the Administrator Gemma G Desos who assisted with the visit.

LPA interviewed the administrator, Wellness Director and resident#1 (R1) and obtained Staff#1 (S1) suspension letter dated on 4/15/22 and termination letter dated on 4/21/22. It was reported that S1 went to R1's room on April 12, 2022 and S1 was handled R1 very rough and rolled R1 towards the wall and hit R1's forehead towards the wall but there's no injury or no marks on her forehead. S1 never apologized to R1 and even went into R1's room the next day and told R1 "I heard you are talking about me to others." R1 felt threatened and nervous. Administrator conducted an internal investigation on April 14, 2022 because R1 did not report the resident until April 14, 2022. S1 was suspended for work on April 15, 2022 and terminated with the company effective on April 21, 2022.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), LPA observed the following deficiency and issued a citation.

An exit interview was conducted and a copy of the Report and Appeal Rights were provided to Administrator Gemma G Deoso.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 04/22/2022 09:23 AM - It Cannot Be Edited

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: 04/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/29/2022
Section Cited

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87468.1 Personal Rights of Residents in All facilities. (a)Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3)(3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature
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The requirement is not me as evidenced by LPA's interview and reported that R1 was handled roughly and caused R1 hit her forehead which imposed a potential risk to residens 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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:
DATE: 04/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/22/2022
LIC809 (FAS) - (06/04)
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