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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191504447
Report Date: 05/05/2022
Date Signed: 05/05/2022 05:19:00 PM

Unsubstantiated


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
04/29/2022 and conducted by Evaluator Christine Wong
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20220429161646
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: 55DATE:
05/05/2022
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Sabina Nayberg- AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Facility did not provide resident with a copy of Admissions Agreement.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Christine Wong and Benette Pena conducted the “Initial 10-Day” visit to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPAs met with Staff #1 (S1) Claudia Flores who allowed entry into the facility and was later met by Administrator Sabina Nayberg who assisted with the visit.

The investigation consised of the following: LPAs Interviewed administrator, six residents (R1-R6) and, three staff (S2-S4) and obtained copy of docunment for R1's face sheet, admission agreement and phyisican report.

The investigation revealed of the following: Allegation#1 " Facility did not provide resident with a copy of Admission Agreement." LPA interviewed six (6) residents and five (5) residents reported they were either never reuqested documents/records from facility or they were able to get the records from facility.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
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 5
Control Number 28-AS-20220429161646
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: 05/05/2022
NARRATIVE
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The administrator reported that resident never requested the copy of admission agreement. In addition, the resident's Power of Attorney (POA) signed the agreement and POA would have been the one to provide the copy the admission agreement for resident, not the facility.

Based on the interviews conducted with the residents and staff and the record review, there was not enough supportive evidence to concur with the reported allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview held. A copy of the report and appeal right was provided to Administrator Sabina Nayberg. .
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
04/29/2022 and conducted by Evaluator Christine Wong
COMPLAINT CONTROL NUMBER: 28-AS-20220429161646

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: 55DATE:
05/05/2022
UNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Sabina Nayberg- AdministratorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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9
Facility does not allow resident to leave facility for an extended period of time.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Christine Wong and Benette Pena conducted the “Initial 10-Day” visit to ascertain information pertaining to the above-mentioned allegation(s) and to establish the validity of the complaint. LPA met with Staff #1 (S1) Claudia Flores who allowed entry into the facility and was later met by Administrator Sabina Nayberg who assisted with the visit.

The investigation consised of the following: LPAs Interviewed administrator, six residents (R1-R6) and, three staff (S2-S4) and obtained copy of docunment for R1's face sheet, admission agreement and phyisicna report.

The investigation revealed of the following: Allegation#1 "Facility does not allow resident to leave facility for an extended period of time." LPA interviewed six (6) residents and five (5) residents reported they either have never left overnight from the facility or they are allowed to leave the facility for an extended period of time. (See LIC9099C for continuation)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20220429161646
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: 05/05/2022
NARRATIVE
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LPA interviewed three staff and two staff reported that the facility has no policy or restriction for resident to leave the facility for an extended period of time as long as resident notify them ahead of time and the facility can prepare resident's medication. Administrator reported the residents are allowed to leave the facility for extended period of time according to the physician report or order. LPAs reviewed the resident#1 physician report and it stated that R1 is able to leave the facility but takes helps. It did not indicate the restriction of time or how many days that R1 can leave. According to the staff and regional nurse, R1 can only leave the facility for three days (72 hours period) based on the new management policy.

Based on LPA’s interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.

An exit interview was conducted and a copy of this report was provided to the Administrator Sabina Navberg along with the Appeals Rights.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20220429161646
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: 05/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/19/2022
Section Cited
CCR
87468.1(a)(6)
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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:(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night.
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The administratrao will ensure the resident has the right to leave or depart the facility at any time. The administrator will retrain the staff for the personal right and send the staff training log to LPA by POC due date.
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The requirement was not met as evidenced by LPA's interviews: LPA interviewed staff and reported resident can only allow to leave facility for 3 days (72 hours) which posed a potential 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: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Christine WongTELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5