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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191504447
Report Date: 06/23/2022
Date Signed: 06/23/2022 11:45:05 AM


Document Has Been Signed on 06/23/2022 11:45 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:SABINA NAYBERGFACILITY TYPE:
740
ADDRESS:5600 GRACEWOOD AVE. #84TELEPHONE:
(626) 442-8410
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY:150CENSUS: 56DATE:
06/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:William Woods (Administrative Assistant)TIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Kruz Long made an unannounced site visit to the facility in an attempted to conduct an annual inspection. Upon arrival, LPA met with William Woods (Administrative Assistant) and explained the purpose of the visit. LPA was made aware the facility had a recent pre-licensing inspection due to ownership change. The effective date on the new license is 06/02/2022 (#198603535). LPA discontinued the annual inspection.

An exit interview was conducted and a copy of this report was provided to Sabina Nayberg (Administrator).
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
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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