198603535-4-21-2022-28-AS-JBAE-CDPU9Y-20220421152355

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603535
Report Date: 04/21/2022
Date Signed: 04/21/2022 03:24:21 PM

Document Has Been Signed on 04/21/2022 03:24 PM - 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 ASSISTED LIVING		FACILITY NUMBER:	198603535
ADMINISTRATOR:	DEOSO, GEMMA		FACILITY TYPE:	740
ADDRESS:	5600 GRACEWOOD AVENUE		TELEPHONE:	(626) 442-8410
CITY:	TEMPLE CITY	STATE: CA	ZIP CODE:	91780
CAPACITY:	150	CENSUS: 55	DATE:	04/21/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Gemma Deoso, Administrator		TIME COMPLETED:	03:22 PM

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On 4/21/22 at 10 :20 a.m., Licensing Program Analysts (LPAs) Jewel Baptiste and Valeria Maldonado conducted an announced visit to the facility for the purpose of a pre-licensing evaluation. LPAs met with Gemma Deoso, administrator, who aided with the tour of the physical plant.

An application was submitted to CCLD on 11/04/2021 for a Change of Ownership for a Residential Care Facility for the Elderly, ages 60 years and older. The fire clearance has been approved for a capacity of 150 residents, which 130 may be non-ambulatory and 20 may be bedridden. Hospice waiver approved for 20.

LPAs inspected and observed the following:

Structure: Facility is a 1- story building with a front lobby/reception area, medication room, dining room, commercial kitchen, pantry, 89 bedrooms, shower room #1-#5, education and storage room,2 Activity room, Lounge, Theater room, Laundry storage room, Beauty shop, public restroom men/women, employee lounge, housekeeping closet, electrical utility closet, hygiene supply closet. Walls, floors, ceilings were observed to be clean and sanitary throughout the building. There are no obstructions to the walkways and/or driveways. There are no pools or bodies of water at the facility.

Bedrooms for Residents: Bedrooms are equipped with a bed, bedframes, dresser, lamps, chairs and adequate closet space. There is adequate lighting throughout the room. LPA tested the signal system in the following rooms: #104, #114, #117, #118, #119, #132, #135, #136, #143, #158. Call signal in room #135 was not working.

Bathrooms: Each residents room have private bathrooms. Some bathtubs have a grab bar and a non-skid mats. Bathrooms missing none skid matts: #104, #106, #114, #131, #136, #157. LPAs observed a broken faucet in room#143 and cracks in tub and grab bars in room #136. Residents that require assistance with transferring are taken to the community shower room for bathing. Common bathroom#1-5 contained shower, grab bars, non-skid matts or strips with shower chairs. Water temperature was taken in bedroom #106 at 91.5, #117 at 125.1, #118 at 122.5, #119 at 125.5, # 143 at 75.5, #135 at 124.9, #132 at 122.6.

Report continued on LIC809

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 ASSISTED LIVING	FACILITY NUMBER: 198603535
	VISIT DATE: 04/21/2022

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Kitchen: LPA observed a food supply that contained more than a 2-day supply of perishables and a 7 day supply of non-perishables from a variety of food groups that met title 22 guidelines. Kitchen counters and preparation areas were observed to be clean and sanitary. Appliances were in working order. Food items were appropriately sealed, labeled and dated. The refrigerator measured at 37.7 degrees and two freezers measured at -11 and -15 degrees that met title 22 guidelines.

Outdoors: The outdoor grounds were toured and observed to be free of debris, obstructions, or hazards. There was a designated section for smoking and a shaded patio with table and chairs accessible for resident use.

Staff and Residents files: Staff and Residents files are stored and maintained at the facility. LPAs randomly selected 6 residents and 5 staff files to ensure all required forms are in their files. The Administrator's certificate expires on 4/6/2023.

Emergency phone numbers, Exit Plan, and Menu: The emergency phone numbers and exit plan are available in the hallways. The menu is posted in the kitchen. The fire extinguishers were last inspected on 12/5/21.

Smoke Detectors: The facility has smoke/carbon monoxide combo detectors in the hall ways and each of the resident rooms, tested in working order. .

Medications, First Aid Kit & Book: Medications are stored and locked in the Wellness office. LPAs randomly selected 3 residents' medication logs to review and all medications are being administered as prescribed. The first aid kit contains all the required supplies along with the current first aid manual.

The facility to submit proof of corrections to correct, the hot water temperature, Broken faucet in room # 143, Cracks in tub and grab bars in room # 136, Skid matts in all rooms and broken call light in room #135.

Component III: LPA Baptiste and Maldonado conducted the component III during today's visit to provide information on how to operate the facility within substantial compliance.

LPA will return at a later date to follow up on the correction. An exit interview was conducted, and this report has been provided to the Executive Director.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel Baptiste	TELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022

LIC809 (FAS) - (06/04)

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