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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198603535
Report Date: 09/28/2023
Date Signed: 09/28/2023 09:23:50 AM


Document Has Been Signed on 09/28/2023 09:23 AM - 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: 121DATE:
09/28/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Staff#1 S1TIME COMPLETED:
09:16 AM
NARRATIVE
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**Please note this is corrected version from previous report dated 7/17/23. Deficiency issued on 7/17/23 has been changed from Type A to Type B. Please see new LIC 809-D page.**

Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management VISIT DEFICIENCIES on 7/17/23 at 10am, stemming from initial complaint investigation on 7/17/23. LPA Ramirez gained entry into the facility at 9:25 am. LPA Ramirez requested and obtained 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 #3 (R3) Face sheet, Physician’s Report, 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 facility Blood Sugar Log for June 26, 2023.

Case Management-Deficiencies findings:

· LPA Ramirez conducted four (4) record reviews of Resident #1, 2,3, and 8 (R1, R2, R3, R8) medical file.

· LPA Ramirez discovered that R1 seen their physician on 6/15/23 and R1’s physician ordered R1 blood sugar to be checked before breakfast, lunch and bedtime. Individual Service Plan (ISP) dated 3/20/2023 states Assisted Living Facility (ALF) will monitor blood sugar 3x/day and will report high or low glucose to MD. LPA Ramirez could only locate documentation for 6/26/23 that indicates facility staff checked R1’s blood sugar. LPA Ramirez could not locate documentation that facility staff checked R1 blood sugar from 6/16/23 to 6/25/23 3x per day as ordered by R1’s physician. · LPA Ramirez discovered that R8 seen their physician on 6/15/23. R8’s physician ordered R8’s blood pressure to be monitored and logged for seven (7) days. R8’s Physician Report dated 6/1/23 indicates R8 should “hold” on taking a certain prescribed medication if R8’s blood pressure is under 100. Facility staff could not provide proof of log to LPA Ramirez.

Deficiencies are being cited. Exit interview was conducted. A copy of this report, 809-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: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 09/28/2023 09:23 AM - 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: 09/28/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/28/2023
Section Cited
CCR
87506(b)(13)

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87506
Resident Records
(b) Each resident’s record shall contain at least the following information:
(13) Continuing record of any illness, injury, or medical or dental care, when it impacts the resident's ability to function or needed services.
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Licensee will certify plan to re-train staff on providing assistance in meeting medical needs of residents and following the physicans orders in regards to medical needs. Licensee will provide proof of staff training attendance sheet by 7/25/23.
*No further action required*
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This requirement is not met as evidence by: R1 physican ordered R1 have blood sugar monitored and recorded 3x a day, R8 physican ordered R8 have blood pressure monitored and recorded. Staff only recorded 1 day of R1's blood sugar and no proof of monitoring or logging of R8 blood pressure.
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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: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023
LIC809 (FAS) - (06/04)
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