198603535-2-7-2023-28-AS-RORN-CUCTNW-20230803145322

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198603535
Report Date: 02/07/2023
Date Signed: 02/07/2023 09:44:02 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
09/02/2022 and conducted by Evaluator Christine Wong

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220902163645

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: 62	DATE:	02/07/2023
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Maya Mnoyan		TIME COMPLETED:	09:55 AM

ALLEGATION(S):

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Resident sustained pressure injuries while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Christine Wong conducted a subsequent visit to ascertain additional information regarding the above-mentioned allegation(s) and for the purpose of rendering the finding. LPA met with receptionist Frances CDeVaca and explained the reason of the visit. Shortly after, LPA met with administrator Maya Mnoyan and assisted with the visit.

The investigation consisted of the following: On 09/07/2022, LPA Wong conducted a health and safety check. LPA toured the facility with LVN Mia Cody and observed that the facility is clean and in good repair. LPA also observed supplies of nonperishable food for a minimum of one week and perishable food for a minimum of two days. Restrooms, hand washing basins, toilets and bathtub/showers are operable. There are no immediate health and safety concerns. The following documents were collected which included: staff and resident roster. Resident#1-#3 (R1-R3) LIC601, physician report, resident appraisal and admission agreement.
(See LIC 9099C for continuation)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

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-20220902163645

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: SANTA ANITA ASSISTED LIVING	FACILITY NUMBER: 198603535
	VISIT DATE: 02/07/2023

NARRATIVE

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On 11/18/22, LPA interviewed five staff (S1-S5) and six residents (R1-R6) and families, facility in house doctor and obtained copy of physician communication report. On today's date, LPA obtained more documents for R1.

The investigation revealed of the following: In regard to the allegation of “Resident sustained pressure injuries while in care.” The staff denied the allegation and reported R1’s wound/blister had been there for a long time and even since she's admitted to the facility three years ago and it's been healing and clean. LPA spoke to home health agency and reported they already discharged R1’s services as there’s no more swelling or redness for R1's blister/wound on her right leg and they reported R1’s thickens skin on hands and foot had been there for a long time and they cannot wash it off.

Based on LPA's observation, interviews conducted with staff and residents, Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations is UNSUBSTANTIATED

An exit interview was conducted, and a copy of this report was provided to Administrator Maya Mnoyan

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323)980-4934
LICENSING EVALUATOR NAME: Christine Wong	TELEPHONE: (323) 981-3963
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC9099 (FAS) - (06/04)

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