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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198603535
Report Date: 07/17/2023
Date Signed: 07/17/2023 05:06:36 PM

Substantiated


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
07/10/2023 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230710131509
FACILITY NAME:SANTA ANITA ASSISTED LIVINGFACILITY NUMBER:
198603535
ADMINISTRATOR:DEOSO, GEMMAFACILITY TYPE:
740
ADDRESS:5600 GRACEWOOD AVENUETELEPHONE:
(626) 442-8410
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY:150CENSUS: 107DATE:
07/17/2023
UNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Maya MnoyanTIME COMPLETED:
05:10 PM
ALLEGATION(S):
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Facility staff are not providing residents with keys to lock their room door.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 07/17/23 regarding the above allegations. LPA Ramirez was met by Staff #1(S1) and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Resident Roster (LIC 9020), Staff #2 - 5 interviews(S2 – S5), Resident #1 – 7 interviews (R1 – R7) Copies of Resident #1 (R1): Face sheet, Physician Visit dated 06/15/23, Identification and Emergency Information form, Physician’s Report dated 3/23/23, Order Summary Report dated 4/5/2023, Individual Service Plan (ISP) dated 3/20/2023, Medication Administration Record (MAR) for May, June and partial month July of 2023, Resident #2 (R2) Face sheet, Physician’s Report dated 5/23/23, Resident #2 and 3(R2, R3) Medication Administration Record (MAR) for May, June and partial month July of 2023, Resident #8(R8) Face sheet, Physician Visit dated 06/15/23, Identification and Emergency Information form, Physician’s Report dated 6/01/23, Order Summary Report dated 6/12/2023, and physical plant tour.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023
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-20230710131509
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: 07/17/2023
NARRATIVE
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The investigation revealed the following. Regarding Allegation(s): Facility staff are not providing residents with keys to lock their room door- It is alleged that facility staff are not providing residents with keys to lock their room door. Two (2) out of five (5) staff interviewed acknowledged that not all residents have keys to their rooms due to some locks on residents’ doors to be is disrepair or not the keys themselves are not working correctly. Seven (7) out of the seven (7) residents interviewed currently do not have keys to lock their room door. Interviews and record review revealed three (3) out of seven (7) residents have been at the facility under 60 days and never received a key to their room. Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Deficiency is being cited. Exit interview was conducted. A copy of this report, 9099-D, 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: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
07/10/2023 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20230710131509

FACILITY NAME:SANTA ANITA ASSISTED LIVINGFACILITY NUMBER:
198603535
ADMINISTRATOR:DEOSO, GEMMAFACILITY TYPE:
740
ADDRESS:5600 GRACEWOOD AVENUETELEPHONE:
(626) 442-8410
CITY:TEMPLE CITYSTATE: CAZIP CODE:
91780
CAPACITY:150CENSUS: 107DATE:
07/17/2023
UNANNOUNCEDTIME BEGAN:
09:27 AM
MET WITH:Maya MnoyanTIME COMPLETED:
05:10 PM
ALLEGATION(S):
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Facility staff are not re-filling medications in a timely manner.
Facility staff are not safe guarding residents personal belongings.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 07/17/23 regarding the above allegations. LPA Ramirez was met by Staff #1(S1) and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Staff Roster (LIC 500), Resident Roster (LIC 9020), Staff #2 - 5 interviews(S2 – S5), Resident #1 – 7 interviews (R1 – R7) Copies of Resident #1 (R1): Face sheet, Physician Visit dated 06/15/23, Identification and Emergency Information form, Physician’s Report dated 3/23/23, Order Summary Report dated 4/5/2023, Individual Service Plan (ISP) dated 3/20/2023, Medication Administration Record (MAR) for May, June and partial month July of 2023, Resident #2 (R2) Face sheet, Physician’s Report dated 5/23/23, Resident #2 and 3(R2, R3) Medication Administration Record (MAR) for May, June and partial month July of 2023, Resident #8(R8) Face sheet, Physician Visit dated 06/15/23, Identification and Emergency Information form, Physician’s Report dated 6/01/23, Order Summary Report dated 6/12/2023, and physical plant tour.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20230710131509
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: 07/17/2023
NARRATIVE
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Facility staff are not re-filling medications in a timely manner. It is alleged facility staff are not re-filling resident medications in a timely manner. Four (4) out of four (4) staff interviewed deny this allegation. LPA Ramirez reviewed three (3) resident MAR for the months May, June and partial of July 2023. LPA Ramirez could not locate and discrepancy to suggest facility did not attempt to refill prescriptions. LPA Ramirez did locate notes in R1 file that indicated facility staff made several attempts to contact physician for prescription refill however, the physician’s office was delaying response. 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.

Facility staff are not safeguarding residents’ personal belongings. It is alleged the facility staff are not safeguarding residents’ personal belongings. Four (4) out of four (4) staff interviewed deny this allegation. Four (4) out of the seven (7) residents interviewed revealed they had items missing from their room in the past however, they did not notify facility staff because some stuff was of nominal value. Residents interviewed could not recall if they misplaced some items of if they were stolen from their room. R2 stated a new cellphone was stolen from their room several weeks ago. R2 revealed they did not notify the facility when the alleged theft occurred. LPA Ramirez could not locate a cell phone listed in R2’s itemized inventory list. 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 was conducted. A copy of this report was provided.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20230710131509
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
07/31/2023
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 develop a plan to address how facility will record lost keys and replacements, how facility will record new residents receiving keys to room. Facility staff provided majority of residents replacement keys to their rooms after report was drafted. Licensee will send list of all residents awaiting replacement keys 7/31/23.
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This requirement is not met as evidence by:
Seven out of the seven residents interviewed do not have keys to lock their rooms. 3 out of the seven residents are have been at the facility less than 60 days and never received a key to their room.
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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: 07/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5