191504447-8-24-2022-28-AS-RORN-CKYQYZ-20221108113558

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191504447
Report Date: 08/24/2022
Date Signed: 08/24/2022 03:43:01 PM

Substantiated

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
09/01/2020 and conducted by Evaluator Elizabeth Ceniceros

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200901131053

FACILITY NAME:	SANTA ANITA RETIREMENT CENTER		FACILITY NUMBER:	191504447
ADMINISTRATOR:	NAFTALI BURSTEIN		FACILITY TYPE:	740
ADDRESS:	5600 GRACEWOOD AVE. #84		TELEPHONE:	(626) 442-8410
CITY:	TEMPLE CITY	STATE: CA	ZIP CODE:	91780
CAPACITY:	150	CENSUS: 53	DATE:	08/24/2022
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Administrator (Sabina Nayberg) and Staff #1 (Administrative Assistant, William Woods)		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Allegation #1: Facility failed to inform family of resident's fall.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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 met by Administrator (A2: Sabina Nayberg) who was later unavailable due to a prior commitment. 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 Angelica Rea on 09/10/20 (via telephone) with (former) Administrator (A1: Marco Villegas) due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures.

LPA/RA Ceniceros interviewed (between 1:00 p.m. - 1:45 p.m.) four (4) facility staff members; however,

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (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 5

Control Number 28-AS-20200901131053

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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA/RA Ceniceros did not interview (former) Resident #1 as the resident moved on 09/08/20 - after three (3) months of residing at the facility. LPA/RA reviewed and requested (between 2:00 p.m. to 3:15 p.m.) pertinent documents (Admissions Agreement, Emergency I.D. & Information, Physician's Report, Pre-placement Appraisal, Medication Administration Records) for Resident #1.

Regarding Allegation #1: this investigation revealed that it's unknown if Resident #1 was hospitalized on 08/29/20 due to a fall on 08/28/20. Prior to the change of ownership, effective 06/02/22, there had been four (4) previous Administrators overseeing the assisted-living facility and each of these Administrators maintained the facility's filing system in various ways. LPA/RA Ceniceros was only able to review "Unusual Incident/Injury Reports") from January 2021 to current. Interviews that were conducted, the majority corroborated that the protocol for reporting requirements is whenever a resident sustains an injury or incident, the resident's primary care physician is notified to determine the care required (first-aid/hospitalization) then the resident's Responsible Person is notified and an incident/injury report is submitted to Licensing within seven (7) days from the date of the incident. Facility was unable to provide documentation ("Unusual Incident/Injury Report") to LPA/RA Ceniceros in regards to Resident #1 having sustained a fall on 08/28/20 and hospitalized on 08/29/20 and notification made to R1's Responsible Person and the incident reported to Licensing.

Based on the evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has been met; therefore, the allegation of REPORTING REQUIREMENTS: Facility failed to inform family of resident's fall is found to be SUBSTANTIATED.

According to the California Code of Regulations (Title 22, Division 6, Chapter 8), the following deficiency was observed and citation issued (ref. LIC 9099D).

An exit interview has been conducted and a copy of the Complaint Report and Appeal Rights were provided to Staff #1 (Administrative Assistant, William Woods).

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (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 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
09/01/2020 and conducted by Evaluator Elizabeth Ceniceros

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200901131053

FACILITY NAME:	SANTA ANITA RETIREMENT CENTER		FACILITY NUMBER:	191504447
ADMINISTRATOR:	NAFTALI BURSTEIN		FACILITY TYPE:	740
ADDRESS:	5600 GRACEWOOD AVE. #84		TELEPHONE:	(626) 442-8410
CITY:	TEMPLE CITY	STATE: CA	ZIP CODE:	91780
CAPACITY:	150	CENSUS: 53	DATE:	08/24/2022
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Administrator (Sabina Nayberg) and Staff #1 (Administrative Assistant, William Woods)		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Allegation #2: Facility failed to seek resident timely medical attention.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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 met by Administrator (A2: Sabina Nayberg) who later was unavailable due to a prior commitment. 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 Angelica Rea on 09/10/20 (via telephone) with (former) Administrator (A1: Marco Villegas) due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures.

LPA/RA Ceniceros interviewed (between 1:00 p.m. - 1:45 p.m.) four (4) facility staff members; however,

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (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: 3 of 5

Control Number 28-AS-20200901131053

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

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Regarding Allegation #2: this investigation revealed that Resident #1 (R1) moved into the facility on 06/25/20 (transferring from a skilled-nursing facility). A review of the resident's "Physician's Report" (dated 06/24/20) documented under "Physical Health Status" that Resident #1 was diagnosed with left-foot gangrene/non- pressure chronic ulcer with unspecified severity. A review of the resident's "Pre-Placement Appraisal Information" (dated 06/23/20) documented that the resident was diabetic.

Based on the evidence gathered and interviews conducted and records reviewed, Resident #1 was diagnosed with gangrene prior to moving into the facility on 06/25/20 based on the "Physician's Report" (dated 06/24/20). 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 NEGLECT/LACK OF SUPERVISION: Facility failed to seek resident timely medical attention is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report and Appeal Rights were provided to Staff #1 (Administrative Assistant, William Woods).

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (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: 4 of 5

Control Number 28-AS-20200901131053

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: 08/24/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/07/2022 Section Cited CCR 87211(a)(1)	1 2 3 4 5 6 7	REPORTING REQUIREMENTS: (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events	1 2 3 4 5 6 7	Licensee/Administrator shall read Section 87211 "Reportig Requirements" and submit a written statement to CCLD (by the POC date 09/07/22) ensuring that the facility will submit to the Licensing Agency and Resident's Responsible Person (within 7 days) of the occurrence any incident/injury that involves a resident at the facility.
	8 9 10 11 12 13 14	specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by: Facility did not have an SIR (dated 08/29/20) regarding R1's hospitalization.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 08/24/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2022

LIC9099 (FAS) - (06/04)

Page: 5 of 5