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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603535
Report Date: 10/14/2025
Date Signed: 10/14/2025 05:16:49 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
10/10/2025 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20251010093333
FACILITY NAME:SANTA ANITA ASSISTED LIVINGFACILITY NUMBER:
198603535
ADMINISTRATOR:JACQUELINE CORTEZFACILITY TYPE:
740
ADDRESS:5600 GRACEWOOD AVENUETELEPHONE:
(626) 442-8410
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY:150CENSUS: 147DATE:
10/14/2025
UNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Jacqueline Cortez, Executive Director TIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff falsified residents' signature.
Staff does not ensure facility is in good repair.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Galarza conducted an initial visit to investigate the above allegation. LPA met with Executive Director Jacqueline Cortez.

The investigation consisted of: A physical plant tour of the interior and exterior was conducted, with special focus on video surveillance, office and break room areas. Records were reviewed. Relevant copies of resident (R1's) file documents were reviewed and obtained, along with facility rosters, job descriptions, and policies.

Refer to LIC 9099C for the continuation of this report.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
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-20251010093333
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 ASSISTED LIVING
FACILITY NUMBER: 198603535
VISIT DATE: 10/14/2025
NARRATIVE
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Allegation: Staff falsified residents' signature. It is alleged that resident (R1's) signature was falsified on "Release of Resident Medical Information" and "Consent for Emergency Medical Treatment.." The complaint alleges that staff falsified their signature so that the resident was able to be seen by the in-house physician, as well as that a med-tech staff falsified R1's signature stating the resident was given their medications on 12/24/24. According to the complaint, R1 was not at the facility on (12/24/25), the date medications were allegedly given to the resident. Staff interviewed denied the allegation. Record review of forms: "Release of Resident Medical Information" and "Consent for Emergency Medical Treatment" did not indicate there was signature falsification because they were electronically signed by R1 on 11/7/24 via Dropbox Sign. However, on 12/24/25, the facility filled out a Medication Release form. Resident (R1's) signature on that date was compared to other document signatures. The signature appears different and inconsistent with the majority of signatures on record. Copies of the Medication Release forms were obtained. There is sufficient evidence to support the allegation.

Allegation: Staff does not ensure facility is in good repair. The complaint alleges the facility surveillance cameras are inoperable. According to information obtained, residents had an understanding the facility has surveillance cameras for their safety. However, in recent months many of the cameras have not been working. A total of 14 residents were interviewed, all the residents interviewed had knowledge of video surveillance in the building. However, the majority of the residents stated they do not know whether all the cameras are operable. Staff interviews confirmed that there are exterior cameras throughout the property, and that the majority of the interior cameras were removed. LPA observed one (1) surveillance camera in the hallway by the lobby area. Executive Director stated the camera video does not show on the main office monitor, and at this time only 3 cameras are displayed in the office surveillance monitor. Based on observation, the facility has multiple cameras, of which only 3 are showing as operable as of today.

Based on observation and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

An exit interview was conducted with Executive Director Jacqueline Cortez. A copy of the report and appeal rights were issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20251010093333
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 ASSISTED LIVING
FACILITY NUMBER: 198603535
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/14/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
10/28/2025
Section Cited
CCR
87207
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False Claims. No licensee, officer or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.

This requirement was not met evidenced by:
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Executive Director agreed to:
1. Provide proof of med-tech in-service training on Medication Release form, and protocols regarding obtaining resident signatures of residents that are unable to sign on their own.
2. Submit a written plan with facility procedures and training materials.
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Based on record review of Medication Release form dated 12/24/24 and multiple other forms on different dates it was observed that form dated 12/24/24's signature is different and inconsistent with the majority of signatures on record. Therefore, there is a signature mismatch. This poses a potential health, safety, and personal rights risk to residents in care.
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Deficiency Dismissed
Type B
11/11/2025
Section Cited
CCR
87303(a)
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Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met evidenced by:
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Executive Director agreed to submit a written plan that addresses surveillance use, policy, and repairs.
If cameras are to be used indoors, the facility plan of operation, sketch, and admission agreement must be updated and submitted to Community Care Licensing.
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Based on observation, there is one (1) indoor surveillance camera located in the hallway by the lobby, and multiple cameras in the exterior of the building. The main office camera monitors only show 3 operable cameras. The indoor camera is not operable. This poses a potential health, safety, and personal rights risk to residents in care.
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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.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 3 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
10/10/2025 and conducted by Evaluator Noemi Galarza
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20251010093333

FACILITY NAME:SANTA ANITA ASSISTED LIVINGFACILITY NUMBER:
198603535
ADMINISTRATOR:JACQUELINE CORTEZFACILITY TYPE:
740
ADDRESS:5600 GRACEWOOD AVENUETELEPHONE:
(626) 442-8410
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY:150CENSUS: 147DATE:
10/14/2025
UNANNOUNCEDTIME BEGAN:
09:22 AM
MET WITH:Jacqueline Cortez, Executive Director TIME COMPLETED:
05:15 PM
ALLEGATION(S):
1
2
3
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5
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9
Staff are not adhering to job duty.
INVESTIGATION FINDINGS:
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5
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13
Licensing Program Analyst (LPA) Galarza conducted an initial visit to investigate the above allegation. LPA met with Executive Director Jacqueline Cortez.

The investigation consisted of: A physical plant tour of the interior and exterior was conducted, with special focus on video surveillance, office and break room areas. Records were reviewed. Relevant copies of resident (R1's) file documents were reviewed and obtained, along with facility rosters, job descriptions, and policies.

Refer to LIC 9099C for the continuation of this report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20251010093333
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 ASSISTED LIVING
FACILITY NUMBER: 198603535
VISIT DATE: 10/14/2025
NARRATIVE
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Allegation: Staff are not adhering to job duty. The complaint alleges that night shift staff have been observed sitting in the main office asleep resting their heads down on the desk after they conduct their rounds. According to information obtained, the staff set alarms to wake up and continue with their rounds, and once they finish doing their rounds they go back to sleep. It is alleged that staff tend to sleep between 12 AM - 4 AM. Based on eight staff interviews, the findings indicate that there is a total of 3 night shift caregiver staff, 2 night shift med-techs, and a receptionist that works from 3:30 PM - 12:00 AM. Caregiver staff are in the main office or break room and med-tech staff are located in the medication room. According to staff interviews, caregivers are required to attend to residents in care and do 2 hourly checks at night. Med-techs pass out medications, respond to incidents and/or emergencies, and organize medications. Two (2) out of the eight (8) staff stated sometimes night shift caregivers do put their head down on the desk, but they are not asleep. A total 14 residents were interviewed. Two (2) out of 14 residents stated they have observed staff sleeping during the night shift hours. It is unknown if night shift staff are on break when they have been seen with their head down on the office counter. Based on interviews conducted, there is insufficient evidence to support the allegation.

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 is Unsubstantiated.

Exit interview conducted with Executive Director Jacqueline Cortez. A copy of the report was issued.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Noemi Galarza
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5