191504447-3-13-2023-28-AS-RORN-CSEMVP-20230602095701

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 191504447
Report Date: 03/13/2023
Date Signed: 03/13/2023 03:37:42 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
12/02/2020 and conducted by Evaluator Angelica Rea

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201202084138

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:	0	CENSUS: 0	DATE:	03/13/2023
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	William Wood, Administrative Assistant		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff neglect resulted in resident being hospitalized
Facility staff did not seek medical attention in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Angelica Rea conducted a subsequent visit to deliver the final results of the investigation. On today's visit, LPA met with Administrative Assistant, William Woods who assisted with the visit.

Regarding the allegation that (1) Staff neglect resulted in resident #1 being hospitalized, and (2) Facility staff did not seek medical attention in a timely manner : The investigation was conducted by the department and consisted of review of resident #1's medical records and resident #1's file, interview(s) with facility staff, resident #1's Power of Attorney, and hospital staff.

The investigation revealed that on 11/30/20 resident #1 was found unconscious by facility staff in resident #1's room. Staff called 911, and resident #1 was taken to the hospital. Facility staff interviewed, indicated that resident #1 had low or no appetite for at least two to three days before being found unconscious in her room.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20201202084138

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: 03/13/2023

NARRATIVE

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Review of medical records, indicate that based on resident #1's condition upon admission to the hospital, resident #1 was found with but not limited to an altered state, a UTI, severely malnourished, greater than 3 days, was extremely dehydrated, and had severe weight loss. Hospital records indicated resident #1 was "critically ill with a high probability of imminent or life threatening deterioration".

Resident #1 did not return to the facility, and passed away on 12/16/20.

Based on LPA's interviews and records reviewed, the preponderance of evidence standard has been met, therefore the allegation is found SUBSTANTIATED. California Code of Regulations Title 22, Division 6, Chapter 8 are being cited on the attached LIC 9099D.

An immediate $500 civil penalty will be issued.

The licensee was informed that a civil penalty might be assessed based on health and safety code 1569.49 (e)or (f).

Exit interview conducted. Civil penalties assessed. Appeal rights explained.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20201202084138

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: 03/13/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/24/2023 Section Cited CCR 87466	1 2 3 4 5 6 7	The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.	1 2 3 4 5 6 7	LIcensee will ensure that residents are being regularly observed for changes in condition. Licensee will provide an in service training to staff and provide proof of training to LPA by POC due date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: facility staff did not ensure that resident #1 was assessed by a medical professional, when it was observed that resident #1 had not been eating or drinking for at least 3 days prior to being found unconscious in her room.	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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

LIC9099 (FAS) - (06/04)

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