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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603535
Report Date: 08/22/2023
Date Signed: 08/22/2023 02:43:03 PM


Document Has Been Signed on 08/22/2023 02:43 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:SANTA ANITA ASSISTED LIVINGFACILITY NUMBER:
198603535
ADMINISTRATOR:MAYA S MNOYANFACILITY TYPE:
740
ADDRESS:5600 GRACEWOOD AVENUETELEPHONE:
(626) 442-8410
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY:150CENSUS: 119DATE:
08/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Maya Mnoyan TIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management Visit-Deficiencies on 8/22/23 at 9am, stemming from initial complaint investigation on 8/22/23. LPA Ramirez gained entry into the facility at 9:03 am. LPA Ramirez was greeted by Staff #1 (S1). LPA Ramirez conducted facility tour with S1.

Case Management-Deficiencies findings:

· LPA Ramirez toured eight (8) resident accommodations. Resident accommodation #129 carpet was observed to be heavily stained with black and brown spotted and scattered stains throughout accommodation. Bathroom was observed to be dirty. LPA Ramirez observed to have hairs and grime around tub. LPA Ramirez observed grime and dirt on floor near toilet. Per R1, carpet has been in disrepair and not clean since R1 moved into the facility in May of 2023.

· Facility was cited on 7/17/23 for 87303 Maintenance and Operation (a) 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. Facility resident door locks were in disrepair which resulted in several residents not receiving keys to lock their accommodation.

· Based on today’s observations, LPA Ramirez is issuing Civil Penalties in the amount of $250 for repeat violations. Thereafter, a civil penalty of $100 per violation per day will be assessed until the violation is corrected.

Deficiencies are being cited. Exit interview was conducted. A copy of this report, 809-D, LIC 421FC and appeals rights was provided.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023
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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Document Has Been Signed on 08/22/2023 02:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/05/2023
Section Cited
CCR
87303(a)

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87303
Maintenance and Operation
(a) 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.
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Licensee will replace carpet or remove stains. Licensee will send picture proof of replaced carpet or invoice of professional carpet cleaning services for room 129. Licensee had staff clean bathroom during visit. No further action required for bathroom correction.
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This requirement is not met as evidence by:
Resident accommodation carpet is disrepair and not clean. Room 129 bathroom tub and floor was observed to be dirty.
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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.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023
LIC809 (FAS) - (06/04)
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