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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 191504447
Report Date: 08/24/2022
Date Signed: 08/24/2022 12:46:47 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
03/24/2020 and conducted by Evaluator Elizabeth Ceniceros
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200324100841
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:
08/24/2022
UNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Administrator (Sabina Nayberg) and Staff #1 (Administrative Assistant, William Woods)TIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff is administering unauthorized medication to resident.

Facility is not allowing resident to receive personal calls.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Staff #1 (S1: Administrative Assistant, William Woods). LPA/RA was later met by Administrator (A2: Sabina Nayberg). LPA/RA spoke to S1 prior to entering the facility to conduct a risk assessment. S1 informed LPA/RA that the facility was cleared and had no COVID cases nor any of the residents or staff have symptoms.

The purpose of today's visit is to conduct a subsequent visit and to deliver the complaint findings pertaining to the above-mentioned allegations. The initial 10-Day virtual visit was conducted by LPA Elizabeth Irra on 04/02/20 (via telephone) with (former) Administrator (A1: Wendy Rivas) due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures.

LPA/RA Ceniceros interviewed (between 8:15 a.m. - 9:00 a.m.) four facility staff members, and attempted
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Araceli RamirezTELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
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 3
Control Number 28-AS-20200324100841
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: 08/24/2022
NARRATIVE
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Witness #1. LPA/RA Ceniceros did not interview (former) Resident #1 due to the resident passed away. LPA/RA requested pertinent documents (Admissions Agreement, Emergency I.D. & Information, Court Documents: Power of Attorney & Restraining Order; Physician's Report, Plan of Care, Resident Appraisal, Hospice Care Notes, Appraisal/ Needs & Services Plan, Medication Administration Records) for Resident #1.

Regarding Allegation #1: this investigation revealed that Resident #1 (R1) received Hospice & Pallative Care, effective 03/24/20 at the facility - approved by R1's physician. [LPA/RA reviewed R1's hospice and pallative care records that documented R1's medication administration noted on a "Current Treatment/Medication List" (from 04/18/20 to 10/01/20) and monitored by hospice registered nurse]. Prior to R1 moving into the facility, Resident #1 was receiving home-based Hospice Care (from 01/11/20 to 04/09/20) through the resident's medical health insurance. [LPA/RA reviewed the home-based hospice care records that documented R1's medication administration noted on a "Frequency and Duration Tracking Sheet" (from 01/11/20 to 04/18/20)]; and, it was monitored by hospice registered nurse. Interviews that were conducted corroborated that the Med Techs were administering Resident #1's medications according to the physician's orders. Documentation was noted on the hospice and pallative care medication list (dated 04/18/20 to 10/01/20). Whenever Resident #1 needed a refill of medications, the Med Techs would contact the hospice agency who would place the order through the pharmacy; and, the medications would be delivered to the facility for Resident #1. A review of the Med Techs training log on the topic: "Eight-Hour Medication Training" was presented on 09/25/20 by a LVN.

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of MEDICATIONS: Staff is administering unauthorized medication to resident is found to be UNSUBSTANTIATED.

Regarding Allegation #2: this investigation revealed based on interviews that were conducted, the majority corroborated that Resident #1 had a landline in the room and a personal cell phone; therefore, the resident would make telephone calls and/or receive personal calls. Resident #1 had a restraining order in place through the Superior Court of California, County of Los Angeles (dated 03/11/20) against two (2) individuals; therefore, the facility could not allow the two (2) family members into the facility or transfer their incoming call to Resident #1 due to the court order and resident's personal rights. A review of Resident #1's records, documented that the resident had an appointed Power of Attorney, effective 02/04/17.

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation

SUPERVISOR'S NAME: Araceli RamirezTELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20200324100841
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: 08/24/2022
NARRATIVE
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may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of PERSONAL RIGHTS: Facility is not allowing resident to receive personal calls is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report was provided to Administrator (Sabina Nayberg) and Staff #1 (Administrative Assistant, William Woods)

SUPERVISOR'S NAME: Araceli RamirezTELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth CenicerosTELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3