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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603535
Report Date: 07/17/2025
Date Signed: 01/30/2026 04:22:48 PM

Document Has Been Signed on 01/30/2026 04:22 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SANTA ANITA ASSISTED LIVINGFACILITY NUMBER:
198603535
ADMINISTRATOR/
DIRECTOR:		JOEL NIBBLETFACILITY TYPE:
740
ADDRESS:5600 GRACEWOOD AVENUETELEPHONE:
(626) 442-8410
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY: 150CENSUS: 146DATE:
07/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:07 AM
MET WITH:Jacqueline Cortez, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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***This is an amendment of the original report. The purpose of the amendment is to add identifiers in the Deficient Practice Statement on the LIC 9099-D (citation). There citations stands and remains the same.***
Licensing Program Analyst (LPA), Mayra Cota, conducted the required annual inspection visit. LPA arrived unannounced and met with Jacqueline Cortez, Executive Director. The purpose of the visit was explained. The facility is licensed for 150 non-ambulatory residents, ages 60 and over, of which (20) may be bedridden. There is a hospice waiver approved for (20) residents. Facility is operating within the scope of its license.

The facility is located in a residential area of Temple City and the building consists of: (89) resident rooms with bathroom included in each room, main entry lobby/lounge, (5) administrative office, medication room, kitchen, (2) dining rooms, (2) patios/courtyards, movie theater room, activities room, (6) staff/visitor restrooms, garden room, staff break room, (2) maintenance/housekeeping storage rooms, chemical room, record room and parking lot.

LPA toured the facility inside and out. LPA, randomly selected (10) resident rooms to inspect as well as the common areas. Hot water temperature in resident bathrooms were tested and measured within the range of 105-120 degree F. Each resident room has the required furniture, closet space, and lighting. However, LPA observed a safety grab bar in (1) resident shower breaking off the wall. The rooms have call buttons located by the resident's beds which were tested and operating during visit. A fireplace was observed and was adequately covered. There are no items nor debris obstructing the walkways. There are no swimming pools or other bodies of water on the premises. The facility has smoke and carbon monoxide combo detectors that are hardwired and connected to the fire department. Several fire extinguishers were also observed throughout the facility and were observed charged. The kitchen was inspected however, several live cockroaches were observed in the dishwashing area, the kitchen sink did not have the hot water warning sign posted by the sink, two dry food containers for rice and oatmeal's lid observed broken and content was exposed and two kitchen staff observed without a hair net during food preparation were observed during visit.
***Continues on LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/17/2025 05:47 PM - It Cannot Be Edited


Created By: Mayra Cota On 07/17/2025 at 03:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SANTA ANITA ASSISTED LIVING
FACILITY NUMBER: 198603535

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
87303(e)(3)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (3) Taps delivering water at 125 degree F (52 degrees C) or above shall be prominently identified by warning signs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having the warning sign posted by the kitchen dishwashing sink for water delivered at 125 degrees F. during inspection, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2025
Plan of Correction
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Licensee will post the warning sign above or by the kitchen dishwashing sink by POC due date and send LPA a photo as proof.
Deficiency Dismissed
Type A
Section Cited
CCR
87303(e)(4)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (4) Grab bars shall be maintained for each toilet, bathtub and shower used by residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that grab bar in shower breaking off the wall in resident bathroom, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2025
Plan of Correction
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Licensee will repair broken grab bar in resident bedroom by POC due date and send LPA a photo of the repair.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/17/2025 05:47 PM - It Cannot Be Edited


Created By: Mayra Cota On 07/17/2025 at 03:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SANTA ANITA ASSISTED LIVING
FACILITY NUMBER: 198603535

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Deficiency Dismissed
Type A
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that several live cockroaches were observed in the dishwashing area of the kitchen during visit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2025
Plan of Correction
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Licensee will contract services for pest control to alleviate the presence of cockroaches. Licensee shall closely monitor the cockroach issue and have the pest control company treat the facility. Licensee will send LPA, invoice of pest control services by POC due date.
Deficiency Dismissed
Type A
Section Cited
CCR
87555(b)(29)
General Food Service Requirements
(b) The following food service requirements shall apply: (29) All equipment, fixed or mobile, and dishes, shall be kept clean and maintained in good repair and free of breaks, open seams, cracks or chips.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not comply with the section cited above in that two dry food containers for rice and oatmeal had broken lids and content was exposed during time of visit, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/18/2025
Plan of Correction
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Licensee will replace broken dry food containers to ensure lids are tight-fitting by the POC due date. Licensee will send a copy of purchased containers and photo of the replaced containers along with their lids.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: SANTA ANITA ASSISTED LIVING
FACILITY NUMBER: 198603535
VISIT DATE: 07/17/2025
NARRATIVE
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Adequate food supplies of 2 day perishable and a week of nonperishable were observed.

Ten (10) staff and (10) resident records were randomly chosen and reviewed. Records reviewed had the required documents in place. Staff are fingerprint cleared and associated to the facility. Resident files contain the admission agreement, medical assessment with TB results, consent forms, property valuable form, pre-appraisal form, and care plan.

Medication review was conducted. Resident medication is centrally stored in the medication room. The facility uses an electronic Medication Administration Record (MAR) log to document medications given. LPA reviewed (10) resident medications; however, medication errors were observed. LPA observed a medication present in the bubble pack and not given to a resident which should have been administered on 7/8/25 (Famotidine 20 mg) Staff interview indicated, they forgot to give the resident the medication at the time it was due for administration. Also, an evening medication was administered too early on 7/17/25. LPA observed missing medication in the evening slot for 7/17/25 (Quetiapine Fumarate 25 mg).

Deficiencies are noted on LIC 809-D.

Exit interview was conducted with Alisa Dean, Business Office Manager due to administrator leaving for a prior engagement, and a copy of this report and Appeal Rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Mayra Cota
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 01/30/2026 04:25 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 01/29/2026 03:00 PM


Created By: Mayra Cota On 07/17/2025 at 05:30 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SANTA ANITA ASSISTED LIVING
FACILITY NUMBER: 198603535

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87465(a)(4)
87465 Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in that LPA observed a medication present in the bubble pack and not given to a resident which should have been administered on 7/8/25 to R1 (Famotidine 20 mg). Staff interview indicated, they forgot to give the resident (R1) the medication at the time it was due for administration. Also, an evening medication was administered too early on 7/17/25 to R4. LPA observed missing medication in the evening slot for 7/17/25 (Quetiapine Fumarate 25 mg), which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 01/31/2026
Plan of Correction
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Licensee will contact the primary physician to notify them of the missed medication. Licensee will also document plan to prevent medication errors. Plan is due by POC due date. Medication training for staff will be conducted and is due by: 7/31/25. LIcense will send training log with personnel in attendance by day of training.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Wei Siew Ho
NAME OF LICENSING PROGRAM MANAGER:
Mayra Cota
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/17/2025


LIC809 (FAS) - (06/04)
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